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Analgesia for forceps delivery

  1. Payam Nikpoor1,*,
  2. Emily Bain2

Editorial Group: Cochrane Pregnancy and Childbirth Group

Published Online: 30 SEP 2013

Assessed as up-to-date: 3 SEP 2013

DOI: 10.1002/14651858.CD008878.pub2


How to Cite

Nikpoor P, Bain E. Analgesia for forceps delivery. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD008878. DOI: 10.1002/14651858.CD008878.pub2.

Author Information

  1. 1

    Lyell McEwin Hospital, Department of Obstetrics and Gynaecology, Elizabeth Vale, Australia

  2. 2

    The University of Adelaide, ARCH: Australian Research Centre for Health of Women and Babies, The Robinson Institute, Discipline of Obstetrics and Gynaecology, Adelaide, South Australia, Australia

*Payam Nikpoor, Department of Obstetrics and Gynaecology, Lyell McEwin Hospital, Haydown Road, Elizabeth Vale, 5112, Australia. payam.nikpoor@gmail.com.

Publication History

  1. Publication Status: New
  2. Published Online: 30 SEP 2013

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Characteristics of included studies [ordered by study ID]
Ellingson 1977

MethodsRandomised controlled trial.


Participants26 women were randomised.

Setting: Bergen, Norway.

Inclusion criteria: women for whom forceps delivery (low forceps, mid forceps and rotation forceps) was indicated due to a delayed second stage of labour (time exceeding 60 minutes).

Exclusion criteria: women with hypertension, pre-eclampsia, epilepsy, premature labour, and suspected or revealed intrauterine asphyxia.


InterventionsDiazepam (n = 13)

Women were administered 30 mg of diazepam intravenously, rapidly, and N2O2 (6+2 litres) was given in a semi-closed system on a mask, to increase the analgesia. If an episiotomy and suturing was required, additional local anaesthesia was infiltrated into the perineum.

Ketamine (n = 13)

Women were administered 2 mg/kg body weight ketamine over 30 seconds intravenously. If a supplementary dose was required, a dose of 1 mg/kg was given after delivery to increase analgesia during suturing.


OutcomesMaternal: maternal opinion of anaesthesia (women were asked to judge whether the anaesthesia was effective: when there was no pain. They were questioned regarding awareness: when the woman claimed to have sensed the operation. Women were also asked when fully conscious whether the recovery was: pleasant/unpleasant); obstetrician opinion of anaesthesia (based on the degree to which restlessness was present during delivery: good, satisfactory, or unsatisfactory). Maternal complications (oxygen requirement due to apnoea, and changes in blood pressure) were reported in the results, however were not pre-specified.

Infant: Apgar score; acid-based estimations. Infant birthweight was also reported in results, however not pre-specified.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot detailed; quote: "allocated at random".

Allocation concealment (selection bias)Unclear riskAs above.

Blinding of participants and personnel (performance bias)
All outcomes
High riskNot detailed, however considered unlikely in view of the interventions.

Blinding of outcome assessment (detection bias)
All outcomes
High riskAs above.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskA number of infant acid-base balance estimations were missing, in an already small sample, with no clear reasons given.

Selective reporting (reporting bias)Unclear riskMaternal complications (ventilation with oxygen, changes in blood pressure) were reported, however were not pre-specified. Infant birthweight was also reported, though not pre-specified, as a mean and a range (no standard deviation given). Apgar scores were reported as ranges only.

Other biasUnclear riskMethods not reported in detail; difficult to judge whether the study was free of other potential sources of bias.

Hutchins 1980

MethodsRandomised controlled trial.


Participants183 women were randomised.

Setting: National Women’s Hospital, Auckland, New Zealand.

Inclusion criteria: women requiring instrumental delivery, with cephalic presentation, for whom regional analgesia had not been provided.

Exclusion criteria: women for whom the "presenting part" was more than 2 cm below the ischial spines.


InterventionsSpinal analgesia (n = 91)

Women received low spinal anaesthesia, administered with a 25-gauge disposable spinal needle, passed through a larger gauge whilst sitting. Lignocaine 1.5 mL 5%, in l0% dextrose, was injected slowly after aspiration and the woman returned passively to the supine position after 2 minutes. Women discouraged from "expulsive efforts".

Pudendal nerve block (n = 92)

Women received pudendal block anaesthesia using a transvaginal technique with 20 mL 1% lignocaine.


OutcomesMaternal: analgesia regarded as adequate/pain inflicted during delivery; requirement for additional analgesia; change in systolic or diastolic blood pressure of more than 10 mmHg; abnormal bladder function; headache; serious complications.

Infant: mean Apgar score.


NotesOutcomes were not pre-specified, and some were incompletely reported.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot detailed; quote: "were randomly allocated".

Allocation concealment (selection bias)Unclear riskAs above.

Blinding of participants and personnel (performance bias)
All outcomes
High riskNot detailed, however considered unlikely in view of the interventions.

Blinding of outcome assessment (detection bias)
All outcomes
High riskAs above.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNo losses or incomplete data reported, however it is difficult to assess whether the data were complete as no total group numbers were reported for individual outcomes (e.g. in the tables only events are reported).

Selective reporting (reporting bias)High riskOutcomes were not pre-specified. A number of outcomes were also incompletely reported, for example: "Mean Apgar scores were similar".

Other biasUnclear riskMethods not reported in detail; difficult to judge whether the study was free of other potential sources of bias.

Mundow 1974

MethodsRandomised controlled trial.


Participants78 women were randomised.

Setting: St James Hospital, Dublin, Ireland.

Inclusion criteria: all forceps deliveries performed by registrars (from January to December 1971).

Exclusion criteria: no exclusion criteria detailed.


InterventionsDiazepam (n = 45)

Women were given 10 mg diazepam intravenously prior to accouchement.

Other (general, local or other anaesthesia) (n = 33)

"Patients received a general, local or other anaesthetic."


OutcomesMaternal: amnesic effect (24 hours after delivery women were asked to recall their delivery) (reported for diazepam group only). Women's behaviour (asleep-rousable, alert, restless, obstreperous) was recorded for the diazepam group only and not pre-specified.

Infant: Apgar score at 2 minutes; neonatal weight changes.


NotesSomewhat unclear if this trial was truly randomised. Whilst it was mentioned "the choice being at random," there was no further detail regarding the methods of randomisation, and the unbalanced group sizes suggest it may not have been a truly random process.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot detailed; quote: "the choice being at random".

Allocation concealment (selection bias)Unclear riskAs above.

Blinding of participants and personnel (performance bias)
All outcomes
High riskNot detailed, however considered unlikely in view of the interventions.

Blinding of outcome assessment (detection bias)
All outcomes
High riskAs above.

Incomplete outcome data (attrition bias)
All outcomes
High riskData reported are incomplete with no maternal outcomes reported for the comparison group. Weight change at day 3 was missing for 1 infant from both groups, with no detail of the reason for these missing data.

Selective reporting (reporting bias)High riskAs above; furthermore, women's behaviour was not pre-specified as an outcome.

Other biasUnclear riskSee above 'Notes.' Methods not reported in detail; difficult to judge whether the study was free of other potential sources of bias.

Sagen 1973

MethodsRandomised controlled trial.


Participants101 women were randomised.

Setting: Bergen, Norway.

Inclusion criteria: women where there was fetal and maternal indication for an operative delivery (including forceps deliveries, and breech deliveries (with the use of piper forceps)).

Exclusion criteria: none detailed.


InterventionsDiazepam (n = 48)

Women were given 30 mg diazepam, dissolved in 9 mL of physiological saline, over 30 seconds.

Vinydan-ether (n = 53)

Women were given vinydan-ether as the mode of general anaesthetic, by an anaesthetic nurse.

All women received 20 mL 1% xylocaine perineal infiltration, atropine intravenously as premedication, and N2O2 8 mL per minute.


OutcomesMaternal: maternal opinion on anaesthesia once fully conscious (effective (no pain) or ineffective; comfortable (no untoward symptoms during induction and recovery) or uncomfortable); obstetrician assessment of anaesthesia (based on degree to which restlessness was present during delivery) (good (the woman was quiet), satisfactory (slight restlessness) or unsatisfactory (so restless as to make delivery disturbed). Maternal complications (vomiting, long-term excitation, aspiration of vomit) and delivery time were reported in results however were not pre-specified.

Infant: Apgar score; acid base estimations in the newborn "were done....Because the numbers in this preliminary study are small....acid-base values have not yet been correlated with clinical states"; these values were not reported.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot detailed; quote: "random selection".

Allocation concealment (selection bias)Unclear riskAs above.

Blinding of participants and personnel (performance bias)
All outcomes
High riskNot detailed, however considered unlikely in view of the interventions.

Blinding of outcome assessment (detection bias)
All outcomes
High riskNot detailed, however considered unlikely in view of the interventions.

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo losses, drop-outs or withdrawals reported. The 3 sets of twins were not included in the delivery time analyses.

Selective reporting (reporting bias)Unclear riskDelivery time and maternal complications were not pre-specified outcomes. Acid-base estimations were collected though were not reported in this paper.

Other biasUnclear riskMethods not reported in detail; difficult to judge whether the study was free of other potential sources of bias.

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Pingsuthiwong 1992This study included pregnant women admitted to the labour ward of Chonburi Hosptial (Thailand), who were in spontaneous labour, with cephalic presentation (i.e. recruitment was not restricted to pregnant women undergoing forceps delivery). Data for forceps delivery only were not reported separately.

 
Comparison 1. Diazepam versus ketamine

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pain relief (judged as effective by the mother)126Risk Ratio (M-H, Fixed, 95% CI)1.42 [0.98, 2.07]

 2 Maternal apnoea requiring oxygen ventilation126Risk Ratio (M-H, Fixed, 95% CI)1.0 [0.07, 14.34]

 3 Apgar score of less than seven at five minutes126Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 4 Acidosis as defined by cord blood arterial pH less than 7.2121Risk Ratio (M-H, Fixed, 95% CI)1.1 [0.08, 15.36]

 5 Good anaesthesia (judged by the obstetrician)126Risk Ratio (M-H, Fixed, 95% CI)0.63 [0.41, 0.97]

 6 Pleasant recovery (judged by the mother)126Risk Ratio (M-H, Fixed, 95% CI)2.08 [1.17, 3.68]

 7 Awareness (mother sensed the operation)126Risk Ratio (M-H, Fixed, 95% CI)0.11 [0.01, 1.88]

 
Comparison 2. Diazepam versus vinydan-ether

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pain relief (judged as effective by the mother)1101Risk Ratio (M-H, Fixed, 95% CI)1.13 [1.02, 1.25]

 2 Vomiting1101Risk Ratio (M-H, Fixed, 95% CI)0.04 [0.00, 0.62]

 3 Apgar score of less than seven at five minutes1104Risk Ratio (M-H, Fixed, 95% CI)1.26 [0.45, 3.50]

 4 Good anaesthesia (judged by the obstetrician)1101Risk Ratio (M-H, Fixed, 95% CI)1.56 [1.11, 2.21]

 5 Comfortable induction and recovery (judged by the mother)1101Risk Ratio (M-H, Fixed, 95% CI)3.45 [2.26, 5.26]

 
Comparison 3. Diazepam versus other (general, local, other anaesthetic)

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Apgar score of less than eight at two minutes178Risk Ratio (M-H, Fixed, 95% CI)1.1 [0.51, 2.38]

 
Comparison 4. Spinal analgesia versus pudendal block anaesthesia

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pain relief (analgesia achieved)1183Risk Ratio (M-H, Fixed, 95% CI)3.36 [2.46, 4.60]

 2 Severe pain during delivery1183Risk Ratio (M-H, Fixed, 95% CI)0.02 [0.00, 0.27]

 3 Serious maternal complications1183Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 4 Request for additional anaesthesia1183Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 5 Maternal hypotension (defined as a decrease in diastolic or systolic blood pressure of more than 10 mmHg)1183Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 6 Headache (mild or moderate)1183Risk Ratio (M-H, Fixed, 95% CI)0.91 [0.53, 1.58]