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Correspondence  |   January 1995
Are Today's Epidurals the 12% Solution?
Author Notes
  • Department of Anesthesiology; St. Louis Regional Medical Center; 5535 Delmar Boulevard; St. Louis, Missouri 63112.
Article Information
Correspondence
Correspondence   |   January 1995
Are Today's Epidurals the 12% Solution?
Anesthesiology 1 1995, Vol.82, 311-312. doi:
Anesthesiology 1 1995, Vol.82, 311-312. doi:
To the Editor:—Do labor epidurals given to nulliparous women contribute to an increased likelihood of cesarean delivery, reported as 25% in the obstetric literature?[1 ] A randomized, controlled trial has demonstrated that some kind of “epidural” increased the incidence of cesarean delivery, as triggered by fetal distress, “arrest of cervical dilatation in the active phase of labor,”“arrest of descent,” or dystocia. [1 ].
The anesthesia methods used for these patients treated between 1990 and 1992 [1 ] are not those currently in use, and for that reason, the general conclusion of that study [1 ] is inapplicable to contemporary practice. Decreasing the dose of bupivacaine from a 0.25% bolus/0.125% maintenance (as in the method of Thorp et al. [1 ]) to a 0.1125% bolus/0.03–0.06% maintenance combined with opioid, Naulty et al. found a significant reduction of cesarean section rate to 10%. [2 ] Recently, two reports from Chestnut et al. described cesarean section rates of 18% and 19% for nulliparous women receiving oxytocin and epidural analgesia early and late in labor [3 ] and 10% and 8% for nulliparous women in spontaneous labor given epidural analgesia early and late in labor. [4 ] Similar to the local anesthetic regimen used by Thorp et al., Chestnut et al. injected 0.25% bupivacaine followed by bupivacaine infusion of 0.125% and no opioid. [3,4 ].
The overall incidence of cesarean section at our hospital, where 3,000 deliveries per year occur, had been 10%, with epidural treatment limited to some patients with hypertensive disorders of pregnancy. Since 1993, the introduction of routinely available epidural analgesia into general use for labor, as “early” as possible for each patient, the historical overall cesarean section rate at our hospital has increased to 12%, a preliminary change of statistical significance by chi-square analysis (Figure 1). This is less than any other major obstetrics center in Missouri; this is clinically acceptable. Our loading and maintenance doses of bupivacaine are 0.125% combined with epidural opioid, often butorphanol or fentanyl.
Figure 1. Stable 10% cesarean section rate for 4 yr at St. Louis Regional Medical Center (squares) surrounded by 95% confidence intervals. Introduction of early labor epidural analgesia is associated with an average cesarean section rate of 12%. Use of labor epidurals (+) increased to about 45%.
Figure 1. Stable 10% cesarean section rate for 4 yr at St. Louis Regional Medical Center (squares) surrounded by 95% confidence intervals. Introduction of early labor epidural analgesia is associated with an average cesarean section rate of 12%. Use of labor epidurals (+) increased to about 45%.
Figure 1. Stable 10% cesarean section rate for 4 yr at St. Louis Regional Medical Center (squares) surrounded by 95% confidence intervals. Introduction of early labor epidural analgesia is associated with an average cesarean section rate of 12%. Use of labor epidurals (+) increased to about 45%.
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That Thorp et al.'s 45 nulliparous patients receiving intravenous meperidine and promethazine had but one cesarean section (2.2%) is impressive. [1 ] A specific comparison of the “best” dilute amide plus opioid labor epidural remains unavailable. Nevertheless, we are not ready to refrain from offering epidural analgesia to nulliparous women in labor, with and without oxytocin augmentation.
Daniel B. Gould, M.D.; Department of Anesthesiology; St. Louis Regional Medical Center; 5535 Delmar Boulevard; St. Louis, Missouri 63112.
(Accepted for publication October 4, 1994.)
REFERENCES
Thorp JA, Hu DH, Albin RM, McNitt J, Meyer BA, Cohen GR, Yeast JD: The effects of intrapartum epidural analgesia in nulliparous labor: A randomized, controlled, prospective trial. Am J Obstet Gynecol 169:851-858, 1993.
Naulty JS, March MG, Leavitt KL, Smith R, Urso PR: Effects of changes in labor analgesia on practice outcome (abstract). Anesthesiology 77:A979, 1992.
Chestnut DH, Vincent RD Jr, McGrath JM, Choi WW, Bates JN: Does early administration of epidural analgesia affect obstetric outcome in nulliparous women who are receiving intravenous oxytocin? Anesthesiology 80:1193-1200, 1994.
Chestnut DH, McGrath JM, Vincent RD, Penning DH, Choi WW, Bates JN, McFarlane C: Does early administration of epidural analgesia affect obstetric outcome in nulliparous women who are in spontaneous labor? Anesthesiology 80:1201-1208, 1994.
Figure 1. Stable 10% cesarean section rate for 4 yr at St. Louis Regional Medical Center (squares) surrounded by 95% confidence intervals. Introduction of early labor epidural analgesia is associated with an average cesarean section rate of 12%. Use of labor epidurals (+) increased to about 45%.
Figure 1. Stable 10% cesarean section rate for 4 yr at St. Louis Regional Medical Center (squares) surrounded by 95% confidence intervals. Introduction of early labor epidural analgesia is associated with an average cesarean section rate of 12%. Use of labor epidurals (+) increased to about 45%.
Figure 1. Stable 10% cesarean section rate for 4 yr at St. Louis Regional Medical Center (squares) surrounded by 95% confidence intervals. Introduction of early labor epidural analgesia is associated with an average cesarean section rate of 12%. Use of labor epidurals (+) increased to about 45%.
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