Intervention Review

Epidural versus non-epidural or no analgesia in labour

  1. Millicent Anim-Somuah1,*,
  2. Rebecca MD Smyth2,
  3. Leanne Jones3

Editorial Group: Cochrane Pregnancy and Childbirth Group

Published Online: 7 DEC 2011

Assessed as up-to-date: 30 SEP 2011

DOI: 10.1002/14651858.CD000331.pub3


How to Cite

Anim-Somuah M, Smyth RMD, Jones L. Epidural versus non-epidural or no analgesia in labour. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD000331. DOI: 10.1002/14651858.CD000331.pub3.

Author Information

  1. 1

    Tameside Hospital NHS Foundation Trust, Ashton-under-Lyne, UK

  2. 2

    The University of Manchester, School of Nursing, Midwifery and Social Work, Manchester, UK

  3. 3

    The University of Liverpool, Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, Liverpool, UK

*Millicent Anim-Somuah, Tameside Hospital NHS Foundation Trust, Fountain Street, Ashton-under-Lyne, OL6 9RW, UK. ma.somuah@tgh.nhs.uk.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 7 DEC 2011

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. Résumé
  5. Résumé simplifié
  6. Plain language summary

Background

Epidural analgesia is a central nerve block technique achieved by injection of a local anaesthetic close to the nerves that transmit pain and is widely used as a form of pain relief in labour. However, there are concerns regarding unintended adverse effects on the mother and infant.

Objectives

To assess the effects of all modalities of epidural analgesia (including combined-spinal-epidural) on the mother and the baby, when compared with non-epidural or no pain relief during labour.

Search methods

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2011).

Selection criteria

Randomised controlled trials comparing all modalities of epidural with any form of pain relief not involving regional blockade, or no pain relief in labour.

Data collection and analysis

Two of the review authors independently assessed trials for eligibility, methodological quality and extracted all data. We entered data into RevMan and double checked it for accuracy. Primary analysis was by intention to treat; we conducted subgroup and sensitivity analyses where substantial heterogeneity was evident.

Main results

We included 38 studies involving 9658 women; all but five studies compared epidural analgesia with opiates. Epidural analgesia was found to offer better pain relief (mean difference (MD) -3.36, 95% confidence interval (CI) -5.41 to -1.31, three trials, 1166 women); a reduction in the need for additional pain relief (risk ratio (RR) 0.05, 95% CI 0.02 to 0.17, 15 trials, 6019 women); a reduced risk of acidosis (RR 0.80, 95% CI 0.68 to 0.94, seven trials, 3643 women); and a reduced risk of naloxone administration (RR 0.15, 95% CI 0.10 to 0.23, 10 trials, 2645 women). However, epidural analgesia was associated with an increased risk of assisted vaginal birth (RR 1.42, 95% CI 1.28 to 1.57, 23 trials, 7935 women), maternal hypotension (RR 18.23, 95% CI 5.09 to 65.35, eight trials, 2789 women), motor-blockade (RR 31.67, 95% CI 4.33 to 231.51, three trials, 322 women), maternal fever (RR 3.34, 95% CI 2.63 to 4.23, six trials, 2741 women), urinary retention (RR 17.05, 95% CI 4.82 to 60.39, three trials, 283 women), longer second stage of labour (MD 13.66 minutes, 95% CI 6.67 to 20.66, 13 trials, 4233 women), oxytocin administration (RR 1.19, 95% CI 1.03 to 1.39, 13 trials, 5815 women) and an increased risk of caesarean section for fetal distress (RR 1.43, 95% CI 1.03 to 1.97, 11 trials, 4816 women). There was no evidence of a significant difference in the risk of caesarean section overall (RR 1.10, 95% CI 0.97 to 1.25, 27 trials, 8417 women), long-term backache (RR 0.96, 95% CI 0.86 to 1.07, three trials, 1806 women), Apgar score less than seven at five minutes (RR 0.80, 95% CI 0.54 to 1.20, 18 trials, 6898 women), and maternal satisfaction with pain relief (RR 1.31, 95% CI 0.84 to 2.05, seven trials, 2929 women). We found substantial heterogeneity for the following outcomes: pain relief; maternal satisfaction; need for additional means of pain relief; length of second stage of labour; and oxytocin augmentation. This could not be explained by subgroup or sensitivity analyses, where data allowed analysis. No studies reported on rare but potentially serious adverse effects of epidural analgesia.

Authors' conclusions

Epidural analgesia appears to be effective in reducing pain during labour. However, women who use this form of pain relief are at increased risk of having an instrumental delivery. Epidural analgesia had no statistically significant impact on the risk of caesarean section, maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores. Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. Résumé
  5. Résumé simplifié
  6. Plain language summary

Epidurals for pain relief in labour

Pain relief is important for women in labour. Pharmacological methods of pain relief include inhalation of nitrous oxide, injection of opioids and regional analgesia with an epidural for a central nerve block. Epidurals are widely used for pain relief in labour and involve an injection of a local anaesthetic into the lower region of the spine close to the nerves that transmit pain. Epidural solutions are given by bolus injection, continuous infusion or using a patient-controlled pump. Lower concentrations of local anaesthetic are needed when they are given together with an opiate, allowing women to maintain the ability to move around during labour and to bear down. Epidural analgesia may sometimes give inadequate analgesia, which may be due to non-uniform spread of local anaesthetic. Combined spinal-epidural involves a single injection of local anaesthetic or opiate into the cerebral spinal fluid for fast onset of pain relief as well as insertion of the epidural catheter for continuing pain relief. Side effects such as itchiness, drowsiness, shivering and fever have been reported and rare but potentially severe adverse effects of epidural analgesia do occur.

The review identified 38 randomised controlled studies involving 9658 women. All but five studies compared epidural analgesia with opiates. Epidurals relieved labour pain better than other types of pain medication but led to more use of instruments to assist with the birth. Caesarean delivery rates did not differ overall and nor were there effects of the epidural on the baby soon after birth; fewer babies needed a drug (naloxone) to counter opiate use by the mother for pain relief. The risk of caesarean section for fetal distress was increased. Women who used epidurals were more likely to have a longer delivery (second stage of labour), needed their labour contractions stimulated with oxytocin, experienced very low blood pressure, were unable to move for a period of time after the birth (motor blockage), had problems passing urine (fluid retention) and suffered fever. Long-term backache was no different. Further research on reducing the adverse outcomes with epidurals would be helpful.

 

Résumé

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. Résumé
  5. Résumé simplifié
  6. Plain language summary

Epidural versus non-epidural or no analgesia in labour

Contexte

Epidural analgesia is a central nerve block technique achieved by injection of a local anaesthetic close to the nerves that transmit pain and is widely used as a form of pain relief in labour. However, there are concerns regarding unintended adverse effects on the mother and infant.

Objectifs

To assess the effects of all modalities of epidural analgesia (including combined-spinal-epidural) on the mother and the baby, when compared with non-epidural or no pain relief during labour.

Stratégie de recherche documentaire

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2011).

Critères de sélection

Randomised controlled trials comparing all modalities of epidural with any form of pain relief not involving regional blockade, or no pain relief in labour.

Recueil et analyse des données

Two of the review authors independently assessed trials for eligibility, methodological quality and extracted all data. We entered data into RevMan and double checked it for accuracy. Primary analysis was by intention to treat; we conducted subgroup and sensitivity analyses where substantial heterogeneity was evident.

Résultats Principaux

We included 38 studies involving 9658 women; all but five studies compared epidural analgesia with opiates. Epidural analgesia was found to offer better pain relief (mean difference (MD) -3.36, 95% confidence interval (CI) -5.41 to -1.31, three trials, 1166 women); a reduction in the need for additional pain relief (risk ratio (RR) 0.05, 95% CI 0.02 to 0.17, 15 trials, 6019 women); a reduced risk of acidosis (RR 0.80, 95% CI 0.68 to 0.94, seven trials, 3643 women); and a reduced risk of naloxone administration (RR 0.15, 95% CI 0.10 to 0.23, 10 trials, 2645 women). However, epidural analgesia was associated with an increased risk of assisted vaginal birth (RR 1.42, 95% CI 1.28 to 1.57, 23 trials, 7935 women), maternal hypotension (RR 18.23, 95% CI 5.09 to 65.35, eight trials, 2789 women), motor-blockade (RR 31.67, 95% CI 4.33 to 231.51, three trials, 322 women), maternal fever (RR 3.34, 95% CI 2.63 to 4.23, six trials, 2741 women), urinary retention (RR 17.05, 95% CI 4.82 to 60.39, three trials, 283 women), longer second stage of labour (MD 13.66 minutes, 95% CI 6.67 to 20.66, 13 trials, 4233 women), oxytocin administration (RR 1.19, 95% CI 1.03 to 1.39, 13 trials, 5815 women) and an increased risk of caesarean section for fetal distress (RR 1.43, 95% CI 1.03 to 1.97, 11 trials, 4816 women). There was no evidence of a significant difference in the risk of caesarean section overall (RR 1.10, 95% CI 0.97 to 1.25, 27 trials, 8417 women), long-term backache (RR 0.96, 95% CI 0.86 to 1.07, three trials, 1806 women), Apgar score less than seven at five minutes (RR 0.80, 95% CI 0.54 to 1.20, 18 trials, 6898 women), and maternal satisfaction with pain relief (RR 1.31, 95% CI 0.84 to 2.05, seven trials, 2929 women). We found substantial heterogeneity for the following outcomes: pain relief; maternal satisfaction; need for additional means of pain relief; length of second stage of labour; and oxytocin augmentation. This could not be explained by subgroup or sensitivity analyses, where data allowed analysis. No studies reported on rare but potentially serious adverse effects of epidural analgesia.

Conclusions des auteurs

Epidural analgesia appears to be effective in reducing pain during labour. However, women who use this form of pain relief are at increased risk of having an instrumental delivery. Epidural analgesia had no statistically significant impact on the risk of caesarean section, maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores. Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes.

 

Résumé simplifié

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. Résumé
  5. Résumé simplifié
  6. Plain language summary

Epidural versus non-epidural or no analgesia in labour

Analgésie péridurale pour le soulagement de la douleur lors de l’accouchement

Le soulagement de la douleur est important pour les femmes qui accouchent. Les méthodes pharmacologiques de soulagement de la douleur incluent l’inhalation d’oxyde nitreux, l’injection d’opiacés et l’analgésie régionale avec péridurale permettant le blocage du système nerveux central. Les péridurales sont couramment utilisées pour soulager la douleur lors de l’accouchement et consistent à injecter un anesthésique local dans la région inférieure du rachis située près des nerfs transmettant la douleur. L’administration des solutions péridurales se fait par injection en bolus, perfusion continue ou utilisation d’une pompe contrôlée par la patiente. Des concentrations inférieures de l’anesthésique local sont requises lorsqu’il est administré avec un opiacé, ce qui permet aux femmes de maintenir leur capacité à se déplacer lors de l’accouchement et pousser. L’analgésie péridurale peut parfois donner lieu à une analgésie inadaptée pouvant résulter d’une diffusion non uniforme de l’anesthésique local. La rachi-péridurale consiste en l’injection unique d’un anesthésique local ou d’un opiacé dans le fluide céphalo-rachidien pour soulager rapidement la douleur, ainsi que pour insérer le cathéter péridural afin de maintenir le soulagement de la douleur. Des effets secondaires, comme des démangeaisons, des vertiges, des frissons et l’apparition de fièvre, ont été signalés et des effets indésirables rares mais potentiellement graves de l’analgésie péridurale peuvent également se produire.

La revue a identifié 38 études contrôlées randomisées, avec un total de 9 658 femmes. Toutes, sauf cinq études, ont comparé l’analgésie péridurale à des opiacés. Les péridurales ont permis de soulager la douleur ressentie lors de l’accouchement mieux que n’importe quels autres types d’analgésiques, mais ont entraîné une augmentation de l’utilisation d’instruments d’aide à l’accouchement. Les taux d’accouchement par césarienne sont restés stables dans l’ensemble, de même que les effets de la péridurale sur le bébé peu après sa naissance. Nous avons noté une diminution de la prescription du médicament (naloxone) administré aux bébés afin de palier la prise d’opiacé par la mère pour soulager sa douleur. Le risque de césarienne en raison de souffrances fœtales a augmenté. Les femmes ayant eu recours à des péridurales ont eu généralement des accouchements plus longs (deuxième étape de l’accouchement), devaient stimuler leurs contractions avec de l’ocytocine, avaient une tension artérielle très basse, ne pouvaient pas bouger pendant un certain temps une fois l’accouchement terminé (blocage moteur), avaient des problèmes urinaires (rétention liquidienne) et souffraient de fièvre. La lombalgie à long terme restait stable. Des recherches supplémentaires pourraient permettre d’évaluer une baisse des résultats indésirables suite à des péridurales..

Notes de traduction

Traduit par: French Cochrane Centre 1st January, 2012
Traduction financée par: Ministère du Travail, de l'Emploi et de la Santé Français

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. Résumé
  5. Résumé simplifié
  6. Plain language summary

Эпидуральная анестезия для облегчения боли в родах

Эпидуральная анестезия для облегчения боли в родах

Облегчение боли важно для женщин в родах. Фармакологические методы облегчения боли включают ингаляции закиси азота, инъекции опиоидов и регионарную с эпидуральной анестезию для обеспечения центральной блокады нерва. Эпидуральная анестезия широко используется для облегчения боли в родах и включает в себя инъекцию местного анестетика в нижнюю часть позвоночника в непосредственной близости к нервам, которые передают боль. Растворы для эпидуральной анестезии вводят путем болюсной инъекции, продолжительной инфузии или с помощью насоса (помпы), контролируемого пациентом. При совместном использовании с опиатами требуются более низкие концентрации местного анестетика, что позволяет женщинам поддерживать способность передвигаться во время родов и тужиться. Эпидуральная анестезия может иногда давать неадекватное обезболивание, связанное с неравномерным распределением местного анестетика. Комбинированная спинально-эпидуральная анестезия включает одну инъекцию местного анестетика или опиата в спинномозговую жидкость для быстрого наступления облегчения боли, а также введение эпидурального катетера для продолжительного обезболивания. Имеются сообщения о побочных эффектах, таких как зуд, сонливость, озноб и лихорадка, а также редкие, и действительно случаются потенциально тяжелые побочные эффекты эпидуральной анестезии.

Этот обзор идентифицировал 38 рандомизированных контролируемых исследований с участием 9658 женщин. Все, кроме пяти исследований сравнивали эпидуральную анестезию с опиатами. Эпидуральная анестезия облегчала боль в родах лучше, чем другие виды обезболивания, но приводила к большему использованию инструментов в родах. Не было разницы в частоте кесаревых сечений в целом, так же как не было влияния эпидуральной анестезии на ребенка вскоре после рождения; меньше детей нуждались в применении антидота (налоксона) для противодействия опиатам, применяемым матерями для облегчения боли. Риск влияния кесарева на дистресс плода был повышен. Женщины, которым применяли эпидуральную анестезию, чаще имели более длительные роды (второй период родов), нуждались в стимулировании родовых схваток окситоцином, испытывали очень низкое кровяное давление, были не в состоянии двигаться в течение определенного периода времени после родов (двигательная блокада), имели проблемы с мочеиспусканием (задержка жидкости) и лихорадку. Различий в частоте отдаленной боли в спине не было. Дальнейшие исследования по снижению неблагоприятных исходов, связанных с эпидуральной анестезии, были бы полезны.

Translation notes

Перевод: Юдина Екатерина Викторовна.

Редактирование: Зиганшина Лилия Евгеньевна.

Координация проекта по переводу на русский язык: Казанский федеральный университет.

По вопросам, связанным с этим переводом, пожалуйста, свяжитесь с нами по адресу: lezign@gmail.com

Translated by: Russian translation team