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Canadian Journal of Anesthesia 49:490-492 (2002)
© Canadian Anesthesiologists' Society, 2002
Obstetrical and Pediatric Anesthesia

Epidural analgesia does not prolong the third stage of labour

[L’analgésie épidurale ne prolonge pas la délivrance lors de l’accouchement]

Ola P. Rosaeg, MB FRCPC, Nicola Campbell, MB CHB FRCA and Mary Lou Crossan, MLT BA

From the Department of Anesthesiology, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.

Address correspondence to: Dr. Ola P. Rosaeg, Department of Anesthesiology, B3, The Ottawa Hospital – Civic Campus, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada. Phone 613-761-4169; Fax: 613-761-5209; E-mail: norse{at}cyberus.ca


   Abstract
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 Abstract
Introduction
 Methods
 Results
 Discussion
 References
 
Purpose: To investigate whether there is an association between epidural analgesia and duration of third stage of labour, and between epidural analgesia and type of placental delivery (spontaneous vs expressed vs manual).

Methods: We examined, retrospectively, the computerized labour and delivery data of all 7,468 parturients who had vaginal deliveries from 1996 to 1999 at the Civic Campus of the Ottawa Hospital.

Results: There was no difference in duration of third stage of labour between women with and without epidural pain relief who had spontaneous or expressed (fundal pressure/gentle cord traction) placental delivery. Duration of third stage of labour was shorter in women with epidural analgesia requiring manual removal of placenta. (25.3 min vs 40.1 min, P < 0.0001). The incidence of expressed placental delivery or manual removal of placenta was not different between the groups.

Conclusions: We conclude that there is no clinically important difference in duration of third stage of labour between women with or without epidural analgesia who have spontaneous placental delivery or placental expulsion with fundal pressure/gentle cord traction. However, duration of third stage of labour was shorter in women who received epidural analgesia and required manual removal of the placenta.


   Introduction
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 Abstract
 Introduction
Methods
 Results
 Discussion
 References
 
META-ANALYSES of clinical trials comparing epidural analgesia with parenteral opioid analgesia have suggested that epidural analgesia, while providing superior pain relief, may prolong first and second stage of labour.1,2 However, another quantitative review of clinical studies of the possible effect of epidural analgesia on outcome of labour concluded that it was unclear whether epidural administration of local anesthetics had any effect on duration of labour.3 A recent randomized clinical trial of parturients with epidural analgesia vs women receiving pain relief with im meperidine during labour also failed to detect a difference between groups in duration of first or second stage of labour.4 A number of recent studies indicate that there is no change or an augmentation in uterine activity after administration of epidural pain relief.5–8

The association between epidural analgesia during labour and the outcome of third stage of labour remains unclear. We therefore conducted a retrospective review of all parturients who delivered per vaginam at the Civic Campus of The Ottawa Hospital during a recent three-year period. We obtained demographic data and recorded the duration of third stage of labour and the method of placental delivery in women with and without epidural labour analgesia.


   Methods
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 Abstract
 Introduction
 Methods
Results
 Discussion
 References
 
Demographic and procedural data were retrieved from the Med2020 Discharge Abstract Database and the Civic Campus Obstetrical Discharge Database. The Obstetrical Discharge Database, an internal customer-defined product of the Civic Campus, was created in 1996 as an electronic Labour, Delivery and Discharge Summary and for report generation. The obstetric chart summary form is completed by hand by physicians and nursing staff and the data is encoded and entered into the database by a Health Record Analyst. The obstetrical data screens were implemented in conjunction with the Med2020 software abstracting system. The data from all deliveries at the Civic Campus of the Ottawa Hospital from January 1, 1996 to December 31, 1998, excluding parturients who delivered by Cesarean section, were retrieved and transferred into a Microsoft Excel data file. Epidural pain relief during labour was provided according to a standard written protocol during this time period, using a continuous infusion of a pre-mixed solution of bupivacaine 0.125% with fentanyl 2 µg•mL-1. After 1998 epidural analgesia was provided with more dilute solutions of different local anesthetics and with combined spinal-epidural analgesia, hence the data from 1999–2000 was not used for analysis.

The statistical analysis of the data was performed with StatView® statistical software using Chi square and ANOVA where appropriate. P < 0.05 was considered statistically significant.


   Results
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 Abstract
 Introduction
 Methods
 Results
Discussion
 References
 
The total number of vaginal deliveries at the Civic Campus of The Ottawa Hospital in the three-year period from January 1, 1996 until December 31, 1998 was 7 468. Of these, 4,954 parturients (66.3%) received epidural pain relief during labour whereas 2,514 received parenteral opioid analgesics or no analgesic medication.

Epidural analgesia was used more frequently in primigravid women and was associated with a higher neonatal birth weight and a greater mean gestational age than parturients who did not receive epidural pain relief (Table IGo). Primigravid women had longer duration of third stage of labour, whether or not they received epidural analgesia (8.5 min vs 7.6 min, P < 0.05). The proportion of women who had expressed (fundal pressure, gentle cord traction) placental delivery or manual removal of placenta was not different between the groups (Table IIGo). The duration of third stage of labour in parturients with spontaneous or expressed placental delivery was not different in women with or without epidural pain relief. The duration of third stage of labour was shorter in patients with epidural analgesia who required manual removal of placenta than women without epidural analgesia who required this intervention (Table IIGo).


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  		TABLE I Demographic data
 

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  		TABLE II Duration of third stage of labour and mode of placental delivery
 

   Discussion
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 Abstract
 Introduction
 Methods
 Results
 Discussion
References
 
The establishment of a detailed Labour and Delivery database at our hospital in 1996 allowed us to retrieve data from a large three-year cohort of parturients, many of whom received epidural analgesia. Hence, we were able to examine, retrospectively, whether there was an association between epidural analgesia and duration of third stage of labour and also between epidural analgesia and mode of placental delivery.

The putative effect of epidural analgesia on the progress and outcome of first and second stage of labour (instrumental delivery and Cesarean section rates) have been studied in some detail by several investigators. Meta-analyses and systemic reviews of clinical trials of the effect of epidural pain relief on duration of first stage of labour suggest that epidural analgesia may be associated with longer first and second stage of labour.1,2 However, the results from a recent large clinical trial suggest that epidural analgesia is not associated with prolonged first or second stage of labour when strict criteria for definition of onset of labour are used and active labour management is employed.4 Impey et al.9 likewise found no increase in the duration of the active phase of second stage of labour in a retrospective, ‘before-and-after’ analysis of the impact of institution of epidural pain relief on outcome of labour in women who received active and standardized labour management.

Our data indicate that there was little difference in the duration of third stage of labour between women who received epidural analgesia and those who did not. But the duration of third stage of labour was shorter in women with epidural analgesia who required manual removal of placenta. Our hypothesis is that epidural analgesia may have provided a ‘permissive’ role; i.e., epidural pain relief provided excellent perineal analgesia which allowed earlier intervention by the obstetrician. Epidural analgesia was not associated with an increased incidence of intervention to deliver the placenta with fundal pressure/gentle cord traction or manual removal of placenta.

Prospective clinical trials have indicated that active management of third stage of labour (including administration of oxytocics and gentle cord traction) results in less post-partum blood loss and lower risk of post-partum hemorrhage compared to expectant, non-interventional management of third stage of labour.10–12 A systematic review of prospective studies of active vs expectant management of third stage of labour confirmed that the risk of post-partum hemorrhage is less in women who receive active management of third stage of labour.13 However, Begley10 noted that active management was associated with more pain than expectant third stage management. A prospective controlled clinical trial is required to not only confirm our retrospective data, but also to determine the extent of pain associated with active management of third stage of labour in women with and without epidural analgesia.

In conclusion, epidural analgesia is not associated with longer duration of third stage of labour in women with spontaneous or expressed placental delivery. However, duration of third stage of labour was shorter in parturients requiring manual delivery of the placenta.


   Acknowledgments
 
The authors would like to thank Ms. Anne Duquette, a Health Record Analyst with the Clinical Information and Records Service at the Civic Campus of the Ottawa Hospital, for expert data management which allowed us to analyze the data using appropriate statistical software.

Revision received February 12, 2002. Accepted for publication December 7, 2001.


   References
TOP
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
1 Howell CJ. Epidural versus non-epidural analgesia for pain relief in labour (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software.

2 Halpern SH, Leighton BL, Ohlsson A, Barrett JFR, Rice A. Effect of epidural vs parenteral opioid analgesia on the progress of labor. A meta-analysis. JAMA 1998; 280: 2105–10.[Abstract/Free Full Text]

3 Zhang J, Klebanoff MA, DerSimonian R. Epidural analgesia in association with duration of labor and mode of delivery: a quantitative review. Am J Obstet Gynecol 1999; 180: 970–7.[Medline]

4 Loughnan BA, Carli F, Romney M, Doré CJ, Gordon H. Randomized controlled comparison of epidural bupivacaine versus pethidine for analgesia in labour. Br J Anaesth 2000; 84: 715–9.[Abstract/Free Full Text]

5 Guidozzi F, Graham KM, Buchmann EJ, Christophers GJ. The effect of continuous low-dose epidural analgesia on uterine work during the active phase of the first stage of labour. S Afr Med J 1992; 81: 361–2.[Medline]

6 Newton ER, Schroeder BC, Knape KG, Bennett BL. Epidural analgesia and uterine function. Obstet Gynecol 1995; 85: 749–55.[Abstract]

7 Lurie S, Feinstein M, Heifetz C, Mamet Y. Epidural analgesia for labor pain is not associated with a decreased frequency of uterine activity. Int J Gynecol Obstet 1999; 65: 125–7.[Medline]

8 Nielsen PE, Abouleish E, Meyer BA, Parisi VM. Effect of epidural analgesia on fundal dominance during spontaneous active-phase nulliparous labor. Anesthesiology 1996; 84: 540–4.[Medline]

9 Impey L, MacQuillan K, Robson M. Epidural analgesia need not increase operative delivery rates. Am J Obstet Gynecol 2000; 182: 358–63.[Medline]

10 Begley CM. A comparison of ‘active’ and ‘physiological’ management of the third stage of labour. Midwifery 1990; 6: 3–17.[Medline]

11 Rogers J, Wood J, McCandlish R, Ayers S, Truesdale A, Elbourne D. Active versus expectant management of third stage of labour: the Hinchingbrooke randomised controlled trial. Lancet 1998; 351: 693–9.[Medline]

12 Quadir Khan G, John IS, Wani S, Doherty T, Sibai BM. Controlled cord traction versus minimal intervention techniques in delivery of the placenta: a randomized controlled trial. Am J Obstet Gynecol 1997; 177: 770–4.[Medline]

13 Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software.





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