Nulliparous active labor, epidural analgesia, and cesarean delivery for dystocia,☆☆,,★★

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Abstract

OBJECTIVE: Our purpose was to examine the effect of epidural analgesia on dystocia-related cesarean delivery in actively laboring nulliparous women.

STUDY DESIGN: Active labor was confirmed in nulliparous women by uterine contractions, cervical dilatation of 4 cm, effacement of 80%, and fetopelvic engagement. Patients were randomized to one of two groups: epidural analgesia or narcotics. A strict protocol for labor management was in place. Patients recorded the level of pain at randomization and at hourly intervals on a visual analog scale. Elective outlet operative vaginal delivery was permitted.

RESULTS: One hundred women were randomized. No difference in the rate of cesarean delivery for dystocia was noted between the groups (epidural 8%, narcotic 6%; p = 0.71). No significant differences were noted in the lengths of the first (p = 0.54) or second (p = 0.55) stages of labor or in any other time variable. Women with epidural analgesia underwent operative vaginal delivery more frequently (p = 0.004). Pain scores were equivalent at randomization, but large differences existed at each hour thereafter. The number of patients randomized did not achieve prestudy estimates. A planned interim analysis of the results demonstrated that we were unlikely to find a statistically significant difference in cesarean delivery rates in a trial of reasonable duration.

CONCLUSIONS: With strict criteria for the diagnosis of labor and with use of a rigid protocol for labor management, there was no increase in dystocia-related cesarean delivery with epidural analgesia.(Am J Obstet Gynecol 1997;177:1465-70.)

Section snippets

Material and methods

Healthy nulliparous women at 36 to 42 weeks' gestation and in spontaneous active labor were candidates for this study. We chose to study only nulliparous patients because, as a group, they are more prone to dystocia and are more likely to require cesarean delivery than are women who have had a previous vaginal birth. Parturients with serious medical problems (e.g., insulin-dependent diabetes mellitus, chronic hypertension requiring medication, pregnancy-induced hypertension, etc.) or those with

Results

During a period of 15 months (August 1995 through October 1996) 100 patients were randomized in this trial: 49 in the epidural group and 51 in the narcotic group. Two women in the epidural group were delivered before obtaining regional analgesia and 12 women in the parenteral analgesia arm eventually received regional analgesia (“epidural rescue”). The “intent to treat” study design specified that these patients remain in their randomized group for all statistical considerations. Table I

Comment

There was no increase in dystocia-related cesarean delivery with epidural analgesia in this trial of spontaneously laboring nulliparous women. We attribute this to several factors. This study had rigid entry requirements that eliminated many of the pitfalls of earlier trials. Without a doubt the patients in this trial were in active labor. Criteria for entry stipulated that the cervix be dilated at least 4 cm, effaced at least 80%, the vertex engaged, and the patient having frequent uterine

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From the Department of Obstetrics and Gynecology, Wright State University School of Medicine,a the Department of Anesthesiology, University of Alabama at Birmingham,b and the Departments of Obstetrics and Gynecologyc and Anesthesiology,d University of Mississippi Medical Center.

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Supported by the Vicksburg Hospital Medical Foundation.

Reprints not available from the authors.

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