1. An Integrative Literature Review
Use of Epidural Anesthesia During Labor Increasing the Risk of Emergency Cesarean Procedures:
An Integrative Literature Review
Maya Rodriguez, RN-MSN
DePaul University, NSG598: Graduate Research Synthesis
Background and Significance
Research Questions
Problem and Purpose
Conceptual Framework
Many complications arise as a result of epidural anesthesia and cesarean procedures. Epidural anesthesia has an associated risk of decreasing the mother’s ability to push stemming from the numbing of the area in the lower half of the spinal region. Therefore, this can result in the need for an emergency cesarean to decrease the risk of fetal distress. The purpose of this integrated literature review is to examine the gaps in knowledge with respects to the use and risks of epidural procedures and associated risks during child birth. This would provide current information to women to make more informed decisions when planning for the birth of their child
Epidural anesthesia, a pain relief used during labor, causes many risks to vaginal labor yet, most, if not all, doctors will administer it if requested. With an epidural, labor can slow down or completely stop if laying in one position, and pushing during a vaginal birth becomes more difficult making it necessary for alternative methods to be used, such as forceps (assisted births) or emergency cesarean procedures. An assisted birth is when an infant requires assistance with instruments, such as forceps, that attach to the head of the infant. Other issues of an epidural include numbness remaining a few hours after birth, and complications where the the needle is inserted, such as permanent nerve damage. In addition, babies may have trouble latching during lactation
The social cognitive model for health Promotion Practice in nursing is fitting because there is a higher likelihood of emergency cesarean procedures resulting from epidural anesthesia than withholding the epidural, and if the goal is a vaginal delivery, proper nursing education on risks of epidural anesthesia will greatly decrease chances of emergency cesarean procedures.
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1. What percentage of emergency cesarean procedures are due to complications of epidural anesthesia?
2. What percentage of women whose goal is having a vaginal birth ask for epidural anesthesia?
3. Is the rate of successful vaginal births relational to the nonuse of epidural anesthesia as compared to the use of it?
Conclusion
Results
Prior to this study, I thought I was going to find that EA increases the rate of CS; however, I found that EA given during the active phase of labor had no effect on emergency CS. Only when EA was administered before the active phase of labor did the risk of emergency CS increase. Other interventions, like forceps, were greatly increased no matter what phase of labor EA was given; however, it was greatly increased if given before the active phase of labor. Something I was not expecting was that EA greatly increased the risk of maternal fever because EA led to longer duration of ruptured membranes, longer labor, more frequent cervical examinations, and other interventions, which induced fever at a higher rate than if EA had not been received. Parenthetically, doctors most likely intervened with an emergency CS if maternal fever was present. Finally, an article by Mousa, Al-Metwalli, and Mostafa claimed that after receiving EA, more oxytocin was needed to keep up labor in order to give birth. If none or not enough oxytocin was received, that was the reason for the prolonged labor. Therefore, prolonged labor is directly relational to maternal fever, making CS more likely.
deliveries observed with epidural use. This result prompted me to do more research on if EA increases maternal fever and if maternal fever directly correlated to increased risk of CS. I found in a study by Scott Segal, Labor Epidural Analgesia and Maternal Fever, women in labor who received EA were at higher risk for fever. EA led to longer duration of ruptured membranes, longer labor, more frequent cervical examinations, and other interventions, which induced fever at a higher rate than if EA had not been received. Finally, doctors were more likely to surgically intervene if maternal fever was present because other risk factors arose; for example, neonatal brain injury or encephalopathy.
Oxytocin Deficiency with Epidural Anesthesia. According to the article by Mousa, Al-Metwalli, and Mostafa, epidural analgesia did not prolong labor compared with parturients without analgesia; however, significant oxytocin augmentation was required during the epidural analgesia to keep up the aforementioned average labor duration. Oxytocin was needed for completion of labor and after labor to prevent bleeding. I wanted to know how EA and oxytocin were related in relation to labor and I found an article by Goodfellow, Hull, Swaab, Dogterom, Buijs explaining that EA blocked the stimulation of pelvic autonomic nerves at crowning which led to oxytocin release.
Stages of Labor. There are three stages of labor: early, active, and transition. Early labor phase is the onset of labor until 3cm is reached. Active phase of labor continues from 3cm to 7cm. Transitional phase of labor continues from 7cm until the cervix is fully dilated to 10cm. According to Klein’s article, anesthesia given before the active phase of labor more than doubled the probability of receiving a cesarean section. If anesthesia was given in the active phase of labor, epidural anesthesia did not increase rates of cesarean sections. This led me to believe that the reason for the increased risk of cesarean section when EA was given before the active phase of labor was most likely due to the inability to feel the uterine contractions leading to fetal distress, and ultimately the necessity of CS. Even if EA was given once the active phase of labor had begun, not being able to push at full capacity posed a great risk and interventions like forceps were likely needed.
Labor Epidural Anesthesia and Maternal Fever. According to the article by Lieberman, Cohen, Lang, Frigoletto, and Goetzl, modest temperature elevation developed during labor was associated with higher rates of cesarean and assisted vaginal deliveries. More frequent temperature elevation among women with epidural analgesia may explain, in part, the higher rates of cesarean and assisted vaginal
Methods
The integrative review of the literature will be guided following the framework of Whittemore and Knafl (2005). The framework will indicate the central stages of the integrative review which will be: problem identification, literature search per data base, data evaluation, data analysis via chart matrix of health care promotion for educating women on the risks of epidural anesthesia and presentation of findings for positive and negative health outcomes. Each study will be examined for efficacy in order to better identify reasons why epidural anesthesia should be avoided during vaginal delivery. The information presented in the integrative literature review can be used by nurses as well as researchers in order to conduct further research on what needs must be addressed in order to spread evidential information to women on risks of epidural anesthesia.
Conceptual Framework