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The controversy of early institution of pain relief via
regional analgesia with modern day epidurals during labor,
resulting in increased risk of cesarean delivery was put to
rest recently
with the publication of a lead article (N Eng J Med
2005;352:655-65) and accompanying editorial (N Eng J
Med 2005;352:718-9) in the New England Journal of
Medicine. Wong
et al (1) conducted a randomized trial of 750 nulliparous
women at term who were in spontaneous labor or had
spontaneous rupture of the membranes and who had a cervical
dilatation of less than 4.0 cm. Women were randomly assigned
to receive the following at the first request of pain
relief. group
1: intrathecal (spinal
part of combined spinal epidural) fentanyl. Epidural
analgesia (epidural part of combined spinal epidural) was
initiated when the women requested further pain relief as
analgesia from the spinal part was decreasing. group
2: systemic (intravenous)
hydromorphone (hydromorphone is narcotic used for pain
relief). Epidural analgesia was initiated in this
group at the request for analgesia if cervical
dilatation was 4.0 cm or greater or at the third request for
analgesia. The
primary outcome studied was the rate of cesarean
delivery. The
authors found no difference in the cesarean delivery between
the groups (17.8 percent in combined spinal/epidural group
vs. 20.7 percent in systemic group); 95% confidence interval
for the difference, -9.0 to 3.0 percentage points; P=0.31).
Furthermore, the duration of labor was shorter following initiation
of combined spinal/epidural than after systemic pain relief
(398 minutes vs. 479 minutes, P=0.001). In addition, babies
were less depressed in the epidural group than in systemic
group (Apgar scores at one-minute was significantly higher
after epidural than after systemic analgesia; 24% vs. 16.7%,
P=0.01). This
study was accompanied by an editorial by DR William Camann
MD, Director of Obstetric Anesthesia, Brigham and Women's
Hospital, Boston, MA. He summarized, the implications of
this study as follows as what it means to all pregnant
women. The
implications of this study were well summarized by DR
William Camann MD, Director of Obstetric Anesthesia, Brigham
and Women's Hospital, Boston, MA, and what they mean
to all pregnant women:(2) "Women
in labor deserve to have as many options as possible at
their disposal to ensure a safe and satisfying birth
experience both for themselves and for their infants. For
women who wish to experience an unmedicated (i.e., natural)
childbirth, an increasingly wide variety of nonpharmacologic
methods
of support are available. However, for those who experience
severe pain in early labor and desire analgesia, the
findings reported by Wong et al. make it clear that safe,
effective pain relief with the use of regional anesthetics
should not be withheld simply because an arbitrary degree of
cervical dilatation has not been achieved." The
implications of this study to pregnant women generated
considerable interest in the public and news media. They can
viewed by clicking on the following: (Close the window to go
to the next item) Boston
Herald New
York Times CNN
The Current opinion of American College
of Obstetricians and Gynecologists on this subject:
In June, 2006, the American College of
Obstetricians and Gynecologists expressed their opinion in a
bulletin (ACOG Committee opinion, Vol 107, NO.6, June 2006)
to all their members. The abstract is as follows:
"Neuraxial analgesia techniques are the
most effective and least depressant treatment for labor and
pain. The American College of Obstetricians and
Gynecologists previously recommended that practitioners
delay initiating epidural analgesia in nulliparous woman
until the cervical dilatation reached 4 cm. However, more
recent studies have shown that epidural analgesia does not
increase the risks of cesarean delivery. The choice of
analgesic technique, agent, and dosage is based on many
factors, including patient preference, medical status, and
contraindications. The fear of unnecessary cesarean
delivery should not influence the method of pain relief that
women can choose during labor."
For a detailed text, please click on
this subject:
ACOG Committee Opinion, Number 339, June 2006. |
