Can sonography represent a marker of dystocia in epidural analgesia? A prospective randomized study

Abstract

Purpose: An association between epidural analgesia and dystocia in the second stage of labor remains controversial. To compare severe labor pain and dystocia at the time of epidural placement for predicting cesarean section (c.s.) risk. We hypothesized, the dystocia causes severe labor pain, such that more epidural medication is required to maintain comfort. Methods: We examined the relationship between labor outcome and severe labor pain defined by the number of supplemental anesthetic boluses, by cervical dilatation, clinical evaluation of pelvic dimension, sonographic fetal weight and ultrasonographic examination of fetal axis in cephalic presenting deliveries. This prospective study included 375 women in labor with have singleton fetuses at term in vertex presentations. We excluded women with pre‐eclampsia, placenta previa, repeat c.s. Results: Seventy‐nine of the 375 patients receiving early epidural analgesia were delivered by c.s. (68 due to dystocia, 11 due to fetal distress). A multiple logistic regression model evaluated demographic and labor‐related variables associations with cesarean risk. By using multivariate analysis, the odds ratio of c.s. among patients who required at least three boluses was 2.4 compared with those who required two boluses or less (P < 0.001). Variables that proved to be statistically significant in increasing the likelihood of c.s. were station at time epidural placement (P < 0.01) and severe labor pain associated with dystocia (P < 0.01). The relationship between severe labor pain‐dystocia and labor arrest (persistent occipito‐posterior or occipito‐transverse position in labor progress) we confirmed with sonography examination during the first and second stage of labor (82% of cases) (P < 0.01). Conclusions: This is a prospective study demonstrating an association between severe labor pain and c.s. The abnormality of fetal axis exists and it can affect the progress of epidural analgesia labors. The sonographic examination in labor reducing the time of labor failure, the possibility of fetal and maternal complications. Furthermore it reduces forensis implications because of the possibility to give evidence of the intrapartum head fetal axis.

The Increasing Trend in Cesarean Sections in South Eastern Italy: Medical and Biopolitical Analysis of Causes and Possible Mechanisms for its Reduction

“…The Vaginal Birth After Caesarean Section (VBAC) rate in North America is declining, mainly in favour of CS: the VBAC rate declined yearly from a peak of 28% in 1996 to less than 10% in 2004 [1]. These increases in CS rates are now far in excess of the optimal CS rate of around 15% suggested in WHO guidelines [4].…”