This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on ISI (115)  • Contact me when this article is cited  Related Content  • Related article  • Similar articles in JAMA  Topic Collections  • Evidence-Based Medicine  • Review  • Alert me on articles by topic

A Meta-analysis

Stephen H. Halpern, MD; Barbara L. Leighton, MD; Arne Ohlsson, MD; Jon F. R. Barrett, MD; Amy Rice, MD

JAMA. 1998;280:2105-2110.

Context.— Epidural labor analgesia, if selected by the patient, is associated with high cesarean delivery rates. Results of randomized trials comparing rates of cesarean delivery using epidural anesthesia vs parenteral opioids are inconsistent.

Objective.— To review the effects of epidural vs parenteral opioid analgesia on cesarean delivery rates.

Data Sources.— Studies were identified by searching MEDLINE from January 1966 through January 1998, the Cochrane Database of Perinatal Trials, and relevant nonindexed journals and abstracts.

Study Selection.— We included all studies that randomized patients to epidural vs parenteral opioid labor analgesia.

Data Extraction.— Two authors independently extracted data from 10 trials enrolling 2369 patients. Odds ratios (ORs) for categorical data, weighted mean differences (WMDs) for continuous data, and 95% confidence intervals (CIs) were calculated using a random-effects model.

Data Synthesis.— The risk of cesarean delivery did not differ between patients receiving epidural (8.2%) vs parenteral opioid (5.6%) analgesia (OR, 1.5; 95% CI, 0.81-2.76). Epidural patients had longer first (WMD, 42 minutes; 95% CI, 17-68 minutes) and second (WMD, 14 minutes; 95% CI, 5-23 minutes) labor stages. While epidural patients were more likely to have instrumented delivery (OR, 2.19; 95% CI, 1.32-7.78), they were no more likely to have instrumented delivery for dystocia (OR, 0.68; 95% CI, 0.31-1.49). After epidural analgesia, neonates were less likely to have low 5-minute Apgar scores (OR, 0.38; 95% CI, 0.18-0.81) or to need naloxone (OR, 0.24; 95% CI, 0.07-0.77). Women receiving epidural analgesia had lower pain scores during the first (WMD, -40 mm on a 100-mm scale; 95% CI, -42 to -38 mm) and second (WMD, -29 mm; 95% CI, -38 to -21 mm) stages of labor. The odds of dissatisfaction were lower with epidural analgesia (OR, 0.25; 95% CI, 0.20-0.32).

Conclusions.— Epidural labor analgesia is not associated with increased rates of instrumented vaginal delivery for dystocia or cesarean delivery. Patients receiving epidural analgesia have longer labors. Patient satisfaction and neonatal outcome are better after epidural than parenteral opioid analgesia.

From the Departments of Anaesthesia (Drs Halpern, Leighton, and Rice), Newborn and Developmental Paediatrics (Dr Ohlsson), and Obstetrics and Gynaecology (Dr Barrett), University of Toronto and Women's College Hospital, Toronto, Ontario. Dr Leighton is Visiting Professor of Obstetrical Anaesthesia, Centre for Women's Health, University of Toronto.

RELATED ARTICLE

December 23/30, 1998
JAMA. 1998;280(24):2185-2186.
EXTRACT | FULL TEXT  

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

A Comparison of the Inhibitory Effects of Bupivacaine and Levobupivacaine on Isolated Human Pregnant Myometrium Contractility
Fanning et al.
Anesth. Analg. 2008;107:1303-1307.
ABSTRACT | FULL TEXT  

Advance Consent in Japanese During Prenatal Care for Epidural Anesthesia During Childbirth
Fetters et al.
Journal of Mixed Methods Research 2007;1:333-365.
ABSTRACT  

Changes in Doppler velocimetry of uterine arteries during labour analgesia
Reynolds et al.
Br J Anaesth 2007;98:274-275.
FULL TEXT  

Continuous Compared With Intermittent Epidural Infusion on Progress of Labor and Patient Satisfaction
Salim et al.
Obstet Gynecol 2005;106:301-306.
ABSTRACT | FULL TEXT  

Prenatal risk factors for Caesarean section. Analyses of the ALSPAC cohort of 12 944 women in England
Patel et al.
Int J Epidemiol 2005;34:353-367.
ABSTRACT | FULL TEXT  

The Risk of Cesarean Delivery with Neuraxial Analgesia Given Early versus Late in Labor
Wong et al.
NEJM 2005;352:655-665.
ABSTRACT | FULL TEXT  

Epidural analgesia in labour
McGrady and Litchfield
Contin Educ Anaesth Crit Care Pain 2004;4:114-117.
ABSTRACT | FULL TEXT  

Rates of caesarean section and instrumental vaginal delivery in nulliparous women after low concentration epidural infusions or opioid analgesia: systematic review
Liu and Sia
BMJ 2004;328:1410.
ABSTRACT | FULL TEXT  

Effects on the fetus and newborn of maternal analgesia and anesthesia: a review: [Les effets de l'analgesie et de l'anesthesie de la mere sur le foetus et le nouveau-ne: une revue]
Littleford
Canadian J. Anesthesia 2004;51:586-609.
ABSTRACT | FULL TEXT  

Different Patterns of Duplicate Publication: An Analysis of Articles Used in Systematic Reviews
von Elm et al.
JAMA 2004;291:974-980.
ABSTRACT | FULL TEXT  

Labour analgesia: what's new and PCEA too?
Campbell
Canadian J. Anesthesia 2003;50:R8-8.
FULL TEXT  

Regional Anesthesia and Analgesia for Labor and Delivery
Jakobi et al.
NEJM 2003;348:1818-1820.
FULL TEXT  

Regional Anesthesia and Analgesia for Labor and Delivery
Eltzschig et al.
NEJM 2003;348:319-332.
FULL TEXT  

Time of day variation in rates of obstetric intervention to assist in vaginal delivery
Webb and Culhane
J. Epidemiol. Community Health 2002;56:577-578.
FULL TEXT  

Epidural analgesia does not prolong the third stage of labour: [L'analgesie epidurale ne prolonge pas la delivrance lors de l'accouchement]
Rosaeg et al.
Canadian J. Anesthesia 2002;49:490-492.
ABSTRACT | FULL TEXT  

Maternal Epidural Use and Neonatal Sepsis Evaluation in Afebrile Mothers
Goetzl et al.
Pediatrics 2001;108:1099-1102.
ABSTRACT | FULL TEXT  

Examining the Evidence in Anesthesia Literature: A Critical Appraisal of Systematic Reviews
T-L. Choi et al.
Anesth. Analg. 2001;92:700-709.
ABSTRACT | FULL TEXT  

Bilateral paravertebral block: a satisfactory alternative for labour analgesia
Nair and Henry
Canadian J. Anesthesia 2001;48:179-184.
ABSTRACT | FULL TEXT  

Ambulatory Labor Epidural Analgesia: Bupivacaine Versus Ropivacaine
Campbell et al.
Anesth. Analg. 2000;90:1384-1389.
ABSTRACT | FULL TEXT  

Obstetric Anesthesiology in the New Millennium
Birnbach
Anesth. Analg. 2000;90:1241-1243.
FULL TEXT  

Epidurals and Cesarean Deliveries: A New Look at an Old Problem
Segal and Birnbach
Anesth. Analg. 2000;90:775-777.
FULL TEXT  

Predictors of Recommendation and Acceptance of Intrapartum Epidural Analgesia
Sheiner et al.
Anesth. Analg. 2000;90:109-109.
ABSTRACT | FULL TEXT  

Other Articles Noted
Evid. Based Nurs. 1999;2:105-112.
FULL TEXT  

Controversies of Labor Epidural Analgesia
Beilin et al.
Anesth. Analg. 1999;89:969-969.
FULL TEXT  

The Risks of Lowering the Cesarean-Delivery Rate
DeMott et al.
NEJM 1999;341:53-55.
FULL TEXT  

Epidural Analgesia and Cesarean Delivery
Herschel et al.
JAMA 1999;281:2084-2087.
FULL TEXT  

RISK FACTORS FOR CESAREAN DELIVERY IN TWIN GESTATIONS NEAR TERM
Halpern et al.
Obstet Gynecol 1999;93:795-795.
FULL TEXT