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 remained controversial 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 ( C) 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 (3 rd & 4 th degree laceration) : may have long term consequence Perineal laceration is more likely when instrumental vaginal delivery is performed Epidural is associated with increased 3 rd & 4 th 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 % 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 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