Selective Epidural Analgesia and the Forceps Rate

Doughty, Andrew

doi:10.1093/bja/41.12.1058

Cited by 64 publications

(11 citation statements)

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“…The observations of Vasicka ef al. Altering lumbar epidural technique leads to a considerable variation in effect (Doughty 1969); perineal and uterine analgesia were present in our patients, but a more localized block may have less effect on pelvic autonomic reflexes, or it may be allowed to wear off before delivery. Altering lumbar epidural technique leads to a considerable variation in effect (Doughty 1969); perineal and uterine analgesia were present in our patients, but a more localized block may have less effect on pelvic autonomic reflexes, or it may be allowed to wear off before delivery.…”

Section: Discussionmentioning

confidence: 87%

Oxytocin Deficiency at Delivery with Epidural Analgesia

Goodfellow

Hull

Swaab

et al. 1983

Obstetric Anesthesia Digest

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The effect of epidural analgesia on oxytocin release during the second stage of normal labour was studied by comparing 10 primigravidae who had epidurals with 10 control subjects who did not have epidurals. A significant increment in oxytocin between paired peripheral blood samples taken at the onset of full cervical dilatation and crowning of the fetal head was found in the control subjects but not in those with epidurals. Forceps delivery was required more often in the group with epidural analgesia and was associated with lower oxytocin levels at crowning. Since distension of the lower birth canal and stimulation of pelvic autonomic nerves leads to oxytocin release, and the need for forceps associated with epidurals can be reduced by oxytocin, these differences are attributed to the lumbar epidural block.During normal delivery stretching of the lower birth canal is thought to trigger a neurohumoral reflex leading to rapid secretion of oxytocin by the pituitary gland which results in strong 'expulsive' contractions (Fitzpatrick 196 1). The reflex is well demonstrated in animal experiments (Debackere

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Section: Discussionmentioning

confidence: 87%

Oxytocin Deficiency at Delivery with Epidural Analgesia

Goodfellow

Hull

Swaab

et al. 1983

Obstetric Anesthesia Digest

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“…Fewer patients required episiotomies or sustained second degree perineal tears in the treatment group (66% v 79%, p=004, table II). No differences were seen between treatment and control groups in terms of BMJ VOLUME 299 Umbilical artery pH at deliveryt 7-25 (0-007) [7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26] (0-008) -0-005 to 0-03 birth weight, umbilical artery pH, Apgar scores, or neonatal morbidity (table IV), and the incidence of fetal distress in the second stage of labour (diagnosed on the basis of abnormalities in the fetal heart rate) was identical (6%). The management of the epidurals seemed similar in the two groups in that the same volume (10 ml) and concentration (0-375%) of local anaesthetic was used in most cases and similar proportions of women had epidural top ups just before and during the second stage of labour (table V).…”

Section: Resultsmentioning

confidence: 99%

Oxytocin infusion during second stage of labour in primiparous women using epidural analgesia: a randomised double blind placebo controlled trial.

Saunders

Spiby

Gilbert

et al. 1989

BMJ

107

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Objective-To determine whether the high rate of forceps delivery associated with the use of epidural analgesia could be reduced through giving an intravenous infusion of oxytocin during the second stage of labour.Design-A randomised, double blind, placebo controlled trial.Setting-Delivery suites in three hospitals. Subjects-226 Primiparous women with adequate epidural analgesia in whom full dilatation of the cervix had been achieved without prior stimulation with oxytocin.Intervention-An infusion of oxytocin or placebo starting at the diagnosis of full cervical dilatation at an initial dose rate of 2 mU/min increasing to a maximum of 16 mU/min.Main outcome measures-The outcome of labour was assessed in terms of the duration of the second stage, mode of delivery, fetal condition at birth, postpartum blood loss, and the incidence of perineal trauma.Results -Treatment with oxytocin was associated with a shorter second stage (p=0-01), a reduction in the number of non-rotational forceps deliveries (p=003), and less perineal trauma (p=0.03) but was not associated with any reduction in the number of rotational forceps deliveries performed for malposition of the occiput. No adverse effects on fetal condition at birth or in the early puerperium were seen in association with the use of oxytocin.Conclusions-The use of an oxytocin infusion may reduce the high rate of operative delivery associated with epidural analgesia provided that the fetal occiput is in an anterior position at the onset of the second stage of labour but within the dose range studied does not seem to correct malposition of the fetal occiput. IntroductionEpidural analgesia has gained widespread acceptance in British obstetric practice in recent years and provides excellent pain relief for women in labour. This degree of analgesia, however, is obtained at a price-namely, an increased requirement for operative vaginal delivery often in association with malposition of the occiput.' 2 Attempts to improve the rate of spontaneous delivery by allowing the analgesia to wear off in the second stage of labour have not been successful,3 and furthermore this manoeuvre defeats the aim of good obstetric analgesia.Allowing a longer second stage of labour in patients with epidurals in conjunction with delayed maternal pushing has been advocated, but the results from

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“…A disadvantage of epidural analgesia often lies in an increased need for instrumental delivery, and we obtained spontaneous delivery in only seven cases. Doughty (1969), however, reported that only 42 per cent of primigravidae needed a forceps delivery, and by encouraging bearing down efforts at the time of the contraction Potter and Macdonald (1971) obtained spontaneous deliveries under epidural-analgesia in up to 71 per cent of patients.…”

Section: Discussionmentioning

confidence: 99%