Unintended effect of epidural analgesia during labor : A systemic review

1. Unintended effect of epidural analgesia during labor : A systemic review presented by R1 顏郁軒 2003/2/6

2. Introduction (1) • American Journal of Obstetric and Gynecology , volume 186 , issue 5 , 2002 May , page S31~ S68 • Epidural analgesia was used by more than half laboring women • No consensus about what unintended effects it causes • Since 1980 , nearly 1900 articles were reviewed

3. Introduction (2) • Cesarean delivery outcomes • Instrumental vaginal delivery outcomes • Spontaneous vaginal delivery outcomes • Epidural techniques & labor outcomes • Newborn outcomes • Maternal postpartum effects

4. Cesarean delivery outcomes • Many studies have noted an association of epidural analgesia with C/S • Whether epidural cause C/S has remainedcontroversial • Epidural itself or difference between women ?

5. Instrumental vaginal delivery outcomes • Instrumental vaginal delivery increased mother & infant consequences • Existing data support an association of epidural with instrumental vaginal delivery • No association for dystocia (?)

6. Spontaneous vaginal delivery outcomes • A lower rate of spontaneous vaginal delivery with epidural

7. Length of labor • First stage of labor : may be longer with epidural • Second stage of labor : existing data strongly support association with epidural

8. Intrapartum fever • Fever (38.0 0C) of women who received epidural analgesia has been documented • Generally believed to result from thermoregulatory alternation rather than infection • Fever effect to the mother & infant • Antibiotics used

9. Fetal malposition • Represent a potential mechanism for C/S or operative vaginal delivery • Observational studies find higher rates of fetal malposition in epidural cases

10. Perineal laceration • Perineal trauma involved anal sphincter (3rd & 4th degree laceration) : may have long term consequence • Perineal laceration is more likely when instrumental vaginal delivery is performed • Epidural is associated with increased 3rd & 4th degree perineal laceration

11. Fetal outcomes • Fetal heart rate change : some evidence of an increased FHR abnormalities in epidural group ; correlated with mother’s temperature • Meconium-stained amniotic fluid , Umbilical cord pH , Apgar score : No association

12. Epidural techniques and Labor Outcomes (1) • Dicontinuation of epidural late in labor :an increased second stage with 0.125% marcaine compared with 0.75% lidocaine • Timing of epidural administration :higher rate of C/S with earlier epidural (<4 or 5 cm) ; instrumental vaginal delivery was probably modest

13. Epidural techniques and Labor Outcomes (2) • Light versus standard epidural : light epidural --> most commonly 0.0625% marcaine with opioid no difference between C/S or instrumental vaginal delivery rate , fetal outcome , but mild longer in first labor stage in light epidural

14. Epidural techniques and Labor Outcomes (3) • Intermittent versus continuous infusion :no significant difference over C/S rate Hypothesized that continuous infusion may be beneficial for the fetus ( avoid large fluctuation of anesthetic level ) : but no large difference was noted over fetus

15. Newborn Outcomes (1) • Neonatal treatment and procedure: study the effect of epidural on neonatal sepsis evaluation and antibiotics treatment * intrapartum fever with epidural used was increased  so sepsis evaluation and antibiotics used were increased

16. Newborn Outcomes (2) • Hyperbilirubinemia :about 1.5 ~ 2 fold increased in the rate of hyperbilirubinemia on epidural • The reason is not clear , but oxytocin & instrumental vaginal delivery may as another explanation

17. Newborn Outcomes (3) • Retinal hemorrhage : perinatal retinal hemorrhage has been demonstrated with vaginal delivery • The rate of retinal hemorrhage was not different on epidural group

18. Newborn Outcomes (4) • Neonatal behavioral and neurologic outcomes :* comparison with nonmedicated infants  no conclusion * comparisons with opioid-exposed infants : epidural group  better on auditory orientation ; opioid group  better muscle tone

19. Newborn Outcomes (5) • Neonatal outcomes and epidural-related fever : • The fever is unlikely to be infectious origin • In primate studies , hyperthermia in the absence of infection , directly associated with development of fetal hypoxia , metabolic acidosis , and hypotension

20. Newborn Outcomes (6) • In adult , stroke with high temperature associated with increased stroke severity , infarct size , and mortality  suggested may increased neurologic injury on infant • The fetal temperature is 0.5 to 0.9 0 C higher than mother

21. Newborn Outcomes (7) • Low Apgar score , hypotonic , required bag & mask resuscitation , and higher rate of seizure • Exception of seizure , the other s/s were noted to be transient

22. Maternal Postpartum Effects (1) • Postpartum hemorrhage and retained placenta :No conclusion

23. Maternal Postpartum Effects (2) • Urinary retention and stress incontinence : • Suggested that delay normal voiding by suppressing afferent sensory impulse from bladder • Not possible to determine from available data where epidural increased the risk of urine retention and stress incontinence

24. Maternal Postpartum Effects (3) • Backache :  current data do not support an association between the use of epidural and development of new , long-term backache

25. Thanks for Your Attention