Maintenance of low-concentration epidural anesthesia does not prolong the second stage of labor or adversely affect maternal and neonatal outcomes, according to new study published online October 10 in Obstetrics & Gynecology.
Between March 2015 and September 2015, XiaoFeng Shen, MD, from the Nanjing Medical University, Jiangsu, China, and colleagues prospectively enrolled 400 nulliparous women who requested epidural anesthesia at the time of spontaneous labor.
All participants received a standard protocol epidural analgesia consisting of an 8- to 10-mL bolus of 0.08% ropivacaine with 0.4 μg/mL sufentanil, followed by an infusion at 8 mL/hour, using a patient-controlled analgesia pump. At full cervical dilation (second stage of labor), participants were randomly assigned (200 in each group) to switch to an epidural saline infusion (placebo) or continuation of the epidural analgesia solution. All those involved were blinded to group assignment. Breakthrough pain was managed with either patient-assisted epidural analgesia or a physician-administered bolus.
Using an intention-to-treat analysis, the researchers found no significant difference in the duration of the second stage of labor between the two groups (52 minutes in the intervention group vs 51 minutes in the saline group; P = .52). The spontaneous vaginal delivery rate was also similar between the two groups (193/200 for the intervention group vs 198/200 for the saline group; P = .17; difference, 3.5%; 95% confidence interval, −0.9% to 5.9%). The authors postulate that the use of a modern low-concentration epidural anesthetic such as the one used in this study may contribute to less motor block, and therefore not hinder maternal expulsive efforts.
Secondary outcomes including neonatal Apgar scores, umbilical blood gas results, and fetal position at delivery were similar between the groups.
With respect to secondary maternal outcomes, the researchers note that pain scores were not statistically different, but did trend upward during delivery for women receiving the saline solution. Similarly, patient satisfaction with pain relief was higher among women receiving analgesia throughout the second stage of delivery.
The study excluded women who received intravenous or oral analgesics during labor, had a history of opioid use, or were receiving magnesium; those with an American Society of Anesthesiologists physical status 3 or 4; and those with cervical dilation of 6 cm or greater at epidural request.
The authors acknowledge the limitations of the study, including the fact that all participants were enrolled at a single center and were all of the same ethnic background, so results may not be applicable to other populations. They also note that their study may have been underpowered to accurately detect the difference in spontaneous vaginal delivery between the two groups.
Although evaluation of these results in women of different ethnic and demographic backgrounds is warranted, “stopping the epidural infusion at the start of the second stage of labor does not affect the duration or any other outcome, with the exception of possibly resulting in lower maternal satisfaction,” the study authors conclude.
The authors have disclosed no relevant financial relationships.
Obstet Gynecol. Published online October 10, 2017.
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