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EFFECT OF NEURAXIAL ANALGESIA ON LABOR PROGRESS: A META-ANALYSIS

Department of Anesthesia, University of Toronto, Women's College Campus, Sunnybrook & Women's College Health Sciences Ctr., 76 Grenville Street, Toronto, Ontario M5S 1B2

INTRODUCTION

Epidural analgesia is associated with a higher incidence of instrumental delivery when compared with iv opioids.(1) This meta-analysis examined the impact of low dose mobile vs high dose epidural analgesia on labor progress with a focus on instrumental delivery.

METHODS

We identified relevant randomized trials using independent searches of computerized databases(PreMEDLINE;MEDLINE; EMBASE; COCHRANE Library; Dissertation Abstracts on Disk) from 1980-Dec 4,2001(all languages, limited to human only). Search terms included: epidural;analgesia;obstetric; labor; bupivacaine; combined spinal epidural and mobile. References of retrieved articles, chapters, abstracts of major conferences, high impact journals and publications of authors of major articles were searched. An attempt was made to locate relevant unpublished studies. "Low dose mobile"(LD) was defined a priori as any low dose initiation (CSE of any type or epidural initiated with bupivacaine <0.125%)followed by a LD maintenance solution containing bupivacaine <0.125%. "High dose"(HD) was defined as initiation / maintenance of analgesia with a solution containing 0.125% bupivacaine. The primary outcome was instrumental delivery. Secondary outcomes included:pruritus; maternal hypotension; nausea; neonatal Apgar scores <7 at 5minutes.

We included all RCTs comparing LD vs HD analgesic regimens, reported mode of delivery, and used bupivacaine as the sole local anesthetic. 2 reviewers independently assessed study relevance, quality and performed data extraction. Agreement was assessed (kappa) and differences resolved by article re-review/consensus.

RESULTS

4 trials(2-5)enrolling 2092 patients were found. Statistical heterogeneity was not found. Pooled odds ratios(OR) and 95%CI were calculated using a random effects model. Results are in the table.

In the LD group, odds of instrumental delivery was significantly reduced while spontaneous vaginal delivery was increased. Cesarean section did not differ between groups. Pruritus was more likely in the LD group. No differences were found in hypotension, nausea, or neonatal Apgar scores at 5minutes.

REFERENCES

1 JAMA 1998;280(24)2105;

2 BJA 1998;81;507;

3 Lancet 1995;345:1413[Medline]

4 NEJM 1997;337:1715; [Abstract/Free Full Text]

5 Lancet 2001;358:19[Medline]

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