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Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia
(Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Analysis 1.1. Comparison 1 Discontinued versus continued, Outcome 1 Instrumental delivery. . . . . . . . . 13
Analysis 1.2. Comparison 1 Discontinued versus continued, Outcome 2 Instrumental delivery by subgroup analysis. 14
Analysis 1.3. Comparison 1 Discontinued versus continued, Outcome 3 Caesarean section. . . . . . . . . . 15
Analysis 1.4. Comparison 1 Discontinued versus continued, Outcome 4 Caesarean section by subgroup analysis. . . 16
Analysis 1.5. Comparison 1 Discontinued versus continued, Outcome 5 Spontaneous vaginal delivery. . . . . . 17
Analysis 1.6. Comparison 1 Discontinued versus continued, Outcome 6 Spontaneous vaginal delivery by subgroup
analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Analysis 1.7. Comparison 1 Discontinued versus continued, Outcome 7 Duration of 2nd stage. . . . . . . . 19
Analysis 1.8. Comparison 1 Discontinued versus continued, Outcome 8 Duration of 2nd stage by subgroup analysis. 20
Analysis 1.9. Comparison 1 Discontinued versus continued, Outcome 9 Fetal malposition. . . . . . . . . . 21
Analysis 1.10. Comparison 1 Discontinued versus continued, Outcome 10 Fetal malposition by subgroup analysis. . 22
Analysis 1.11. Comparison 1 Discontinued versus continued, Outcome 11 Inadequate pain relief. . . . . . . . 23
Analysis 1.12. Comparison 1 Discontinued versus continued, Outcome 12 Inadequate pain relief by subgroup analysis. 24
Analysis 1.13. Comparison 1 Discontinued versus continued, Outcome 13 Apgar score < 7 or < 8 at 1 minute. . . 25
Analysis 1.14. Comparison 1 Discontinued versus continued, Outcome 14 Apgar score < 7 or < 8 at 1 minute by subgroup
analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Analysis 1.15. Comparison 1 Discontinued versus continued, Outcome 15 Apgar score < 7 at 5 minutes. . . . . 27
Analysis 1.16. Comparison 1 Discontinued versus continued, Outcome 16 Umbilical arterial pH. . . . . . . . 27
Analysis 1.17. Comparison 1 Discontinued versus continued, Outcome 17 Umbilical arterial pH by subgroup analysis. 28
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia i
(Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]
Contact address: Siranda Torvaldsen, Public Health Officer Training Program, School of Public Health and Community Medicine, Uni-
versity of New South Wales, Room 317, Level 3, Samuels Building, Sydney, New South Wales, 2052, Australia. siranda@unsw.edu.au.
Citation: Torvaldsen S, Roberts CL, Bell JC, Raynes-Greenow CH. Discontinuation of epidural analgesia late in labour for reducing
the adverse delivery outcomes associated with epidural analgesia. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.:
CD004457. DOI: 10.1002/14651858.CD004457.pub2.
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
ABSTRACT
Background
Although epidural analgesia provides the most effective labour analgesia, it is associated with some adverse obstetric consequences,
including an increased risk of instrumental delivery. Many centres discontinue epidural analgesia late in labour to improve a woman’s
ability to push and reduce the rate of instrumental delivery.
Objectives
To assess the impact of discontinuing epidural analgesia late in labour on:
i) rates of instrumental deliveries and other delivery outcomes; and
ii) analgesia and satisfaction with labour care.
Search methods
We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (October 2007).
Selection criteria
Randomised controlled trials of epidurals discontinued late in labour compared with continuation of the same epidural protocol until
birth, in women who receive an epidural for analgesia in the first stage of labour.
Data collection and analysis
Two review authors independently assessed study eligibility and quality and extracted the data. We analysed categorical data using
relative risk (RR), and continuous data using weighted mean difference.
Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia 1
(Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Main results
We identified six studies, of which five were included (462 participants). Three of these were high-quality studies whilst the other
two were judged to be of lower quality because placebo was not used and the method of randomisation not described. All studies
used different epidural analgesia protocols (type of drug, dosage or method of administration). Overall, the reduction in instrumental
delivery rate was not statistically significant (23% versus 28%, RR 0.84, 95% confidence interval (CI) 0.61 to 1.15) nor was there
any statistically significant difference in rates of other delivery outcomes. The only statistically significant result was an increase in
inadequate pain relief when the epidural was stopped (22% versus 6%, RR 3.68, 95% CI 1.99 to 6.80).
Authors’ conclusions
There is insufficient evidence to support the hypothesis that discontinuing epidural analgesia late in labour reduces the rate of in-
strumental delivery. There is evidence that it increases the rate of inadequate pain relief in the second stage of labour. The practice of
discontinuing epidurals is widespread and the size of the reduction in instrumental delivery rate could be clinically important; therefore,
we recommend a larger study than those included in this review be undertaken to determine whether this effect is real or has occurred
by chance, and to provide stronger evidence about the safety aspects.
Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural
analgesia
Not enough evidence to suggest that stopping an epidural late in labour lowers the risk of instrumental delivery or other unwanted
outcomes.
Epidurals are used for pain relief in labour, but they increase the risk of instrumental delivery (vacuum/forceps). Stopping epidurals
early aims to allow women to feel the pushing urge and so reduce the chance of having an instrumental birth and possible problems
associated with such a birth. There is not enough evidence from the five included trials, involving 462 participants, to show whether
stopping an epidural really does lower the risk of instrumental delivery or of any other unwanted outcome. The results show that
women whose epidural is stopped report more pain than women whose epidural is continued until the birth of the baby. More research
is needed.
Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia 3
(Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
We did not apply any language restrictions. except Johnsrud 1988 specified that the women were healthy or
had uncomplicated pregnancies, or both. All women had epidural
analgesia initiated in the first stage of labour. The epidural infu-
Data collection and analysis sion or top-ups were then either stopped or replaced with a study
solution (either the same solution or saline) late in labour. Four
Two review authors independently assessed trials for inclusion in studies specified that this occurred either at at least eight centime-
the review. We assessed the methodological quality according to tres or more than eight centimetres whilst Johnsrud 1988 stated
the criteria in the Cochrane Reviewers’ Handbook (Clarke 2003), that the study group were without infusion analgesia in the second
with a grade allocated to each trial on the basis of allocation con- stage but did not specify exactly when it was switched off.
cealment: A (adequate), B (unclear), C (clearly inadequate). For In three studies (Chestnut 1987a; Chestnut 1987b; Chestnut
all trials we documented details regarding randomisation method, 1990), the continuous epidural infusion solution syringe was sub-
completeness of follow up, use of placebo, blinding of outcome stituted with a syringe containing the study solution when the
measurement and analysis in randomised groups. woman’s cervix was eight or more centimetres dilated. These stud-
Two review authors independently extracted data using prepared ies were methodologically almost identical, all involving replacing
data extraction forms. We performed statistical analyses using the the continuous epidural infusion solution with a study solution
Review Manager software (RevMan 2003). We analysed categor- which contained either the same drug or a placebo (saline). The dif-
ical data using relative risk and continuous data using weighted ferences between these studies were the drug(s) used in the epidu-
mean difference. We used sensitivity analyses to evaluate the ef- ral solution. Chestnut 1987a used 0.75% lidocaine, Chestnut
fect of the trial quality. We measured heterogeneity using the I2 1987b used 0.125% bupivacaine and Chestnut 1990 used a low-
statistic. As there was no significant heterogeneity, we used a fixed- dose local anaesthetic plus an opioid (0.0625% bupivacaine plus
effect model to pool results. 0.0002% fentanyl). In one study (Johnsrud 1988) women receiv-
ing a continuous epidural infusion were also studied but, unlike the
Chestnut studies, there was no placebo. Only one study (Luxman
1996) used intermittent boluses, commonly referred to as ’top-
RESULTS ups’. The women in the study group did not receive any more
top-ups after the cervix was eight centimetres dilated, whilst the
women in the control group continued to receive top-ups until
Description of studies delivery. In this study, labour was managed actively, using rou-
tine amniotomy on admission for all women not presenting with
Six potentially eligible trials were identified, of which five were spontaneous rupture of membranes and oxytocin was given when
included. No potentially relevant on-going trials or trials awaiting cervical dilatation was less than one centimetre per hour.
assessment were identified.
Excluded study
One study (Phillips 1983) was excluded because for 27% of the Risk of bias in included studies
study participants, the reason for the epidural was obstetric or
medical rather than analgesia (see Table of ’Characteristics of ex-
cluded studies’). In addition, this trial was of poor methodological
quality. Participants were randomised by shuffling sheets and it
High-quality studies
was not placebo controlled. When the fetal head was below the
ischial spines, no further top-ups of bupivacaine 0.25% were given The high-quality studies were the three Chestnut studies (
to women in the study group. There was no significant difference Chestnut 1987a; Chestnut 1987b; Chestnut 1990) where the
in the total dose of bupivacaine received by women in the study study solutions were prepared and coded by the hospital pharma-
and control groups. cist according to a table of random numbers. The patient, anaes-
thesiologist, obstetrician, paediatrician, and nursing staff were un-
aware of the identity of the study solution. These three studies did
Included studies have exclusions which were due to protocol violations or because a
Five studies were included (Chestnut 1987a; Chestnut 1987b; caesarean section was performed after the initiation of the epidural
Chestnut 1990; Johnsrud 1988; Luxman 1996) with a total of but before substitution of the epidural infusion solution with the
462 participants (see Table of ’Characteristics of included studies’). study solution (between 11% and 18% of eligible study partici-
All participants were women in labour with their first baby, which pants). Four women in the Chestnut 1990 study were excluded
was a term singleton fetus of vertex presentation. All the studies for protocol violations postrandomisation.
Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia 4
(Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Lower-quality studies (4) Duration of the second stage of labour
The other two studies (Johnsrud 1988; Luxman 1996) were not All studies compared the length of second stage of labour between
placebo controlled and the method of randomisation was not de- the study and control group but only three studies (Chestnut
scribed. The Johnsrud 1988 study had exclusions for the same rea- 1987a; Chestnut 1987b; Luxman 1996), with 203 participants in
sons as the Chestnut studies but did not state when the protocol total, reported the mean duration in minutes with standard devi-
violations or caesarean sections occurred. Caesarean section is an ation. Meta-analysis of these three studies showed no statistically
important outcome measure but its incidence could not be calcu- significant or clinically important difference in the length of sec-
lated from this study and, because of this, neither could the inci- ond stage (weighted mean difference (WMD) -5.80 minutes, 95%
dence of spontaneous vaginal delivery. The Luxman 1996 study CI -12.91 to 1.30). It should be noted that the assumptions of the
had four postrandomisation exclusions for caesarean sections (two analysis may have been violated due to duration of second stage
in each group) which were not included in their analyses. of labour often being non-normally distributed as a result of a few
None of the longer-term outcomes (maternal satisfaction with women having very long second stages. In addition, there is some
labour care, incidence of postpartum urinary incontinence, fecal heterogeneity in this outcome (I-squared statistic = 41.8%) One
incontinence and sexual problems) were reported in any of the other study (Johnsrud 1988) reported no significant difference in
studies. mean length of second stage (37 minutes versus 38 minutes) but
could not be included in the meta-analysis because no standard
deviation was reported. The remaining study (Chestnut 1990) re-
Effects of interventions ported median length of second stage and found no significant
difference (63 minutes versus 53 minutes).
Five studies were included (Chestnut 1987a; Chestnut 1987b;
Chestnut 1990; Johnsrud 1988; Luxman 1996) with a total of
462 participants. (5) Incidence of fetal malposition at delivery
All studies except Luxman 1996 reported the number of persis-
(1) Incidence of instrumental delivery tent fetal malpositions (occipitoposterior and occipitotransverse
positions plus one case of deflection). Of the 388 participants in
All studies reported the incidence of instrumental delivery. The
whom this was measured, 36 (9%) had persistent malpositions.
overall incidence of instrumental delivery varied considerably
No studies showed any significant difference between the study
among the studies, from 15% in Luxman 1996 to 35% in
and control group with a pooled relative risk of 1.36 (95% CI
Chestnut 1987b. The meta-analysis showed no statistically signif-
0.73 to 2.56).
icant reduction in the incidence of instrumental deliveries (23%
versus 28%, relative risk (RR) 0.84, 95% confidence interval (CI)
0.61 to 1.15).
(6) Reporting of inadequate pain relief during the
second stage of labour
(2) Incidence of caesarean section All studies except Luxman 1996 reported a measure of pain relief.
All studies except Johnsrud 1988 reported the number of caesarean We defined inadequate pain relief as either ’poor’ or ’very poor’ on
sections performed postrandomisation. Meta-analysis showed no a five point scale or ’poor’ on a four point scale. Meta-analysis of
significant difference in the rate of caesarean sections (RR 0.98, the four studies (384 participants) found a statistically significant
95% CI 0.43 to 2.25). It should be noted that, overall, caesarean increase in inadequate pain relief in the study group (22% versus
section was an infrequent outcome, occurring in only 18 of the 6%, RR 3.68, 95% CI 1.99 to 6.80).
282 (6%) participants in whom it was reported.
Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia 5
(Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
reported the number of babies with Apgar scores less than seven (2) By type of epidural analgesia (intermittent bolus,
whilst Johnsrud 1988 reported the number of babies with Apgar continuous infusion or combined spinal epidural)
scores less than eight. Of these 388 participants, 57 (15%) had Four studies used a continuous epidural infusion (Chestnut 1987a;
low Apgar scores (defined as either less than 7 or less than 8) at one Chestnut 1987b; Chestnut 1990; Johnsrud 1988), one (Luxman
minute. Meta-analysis showed no statistically significant difference 1996) used intermittent boluses (top-ups), and none used com-
between the two groups (RR 1.55, 95% CI 0.94 to 2.55). bined spinal epidural. There was no evidence that the intervention
had different effects on these subgroups.
(11) Incidence of low umbilical arterial pH This review is limited by the small number of studies and par-
ticipants, and the only confident conclusion to be drawn is that
The three Chestnut studies measured umbilical arterial pH. There discontinuing epidural analgesia late in labour increases the rate
was no significant difference between the two groups in any study, of inadequate pain relief during the second stage of labour. Whilst
nor in the meta-analysis (208 participants, WMD -0.01, 95% CI it is possible that discontinuing epidural analgesia reduces the in-
-0.03 to 0.01). cidence of instrumental delivery, at present there is insufficient
evidence to accept or refute this. A 16% reduction in instrumental
delivery rates may be clinically important, but a much larger study
(12) Incidence of urinary incontinence postpartum than any of those included in this review would be needed to deter-
This outcome was not reported in any of the studies. mine the real impact of the intervention. The only study (Chestnut
1987b) in which the intervention group had a significantly shorter
second stage of labour was also the only study where the study
group had a significantly lower rate of instrumental delivery and a
(13) Incidence of fecal incontinence postpartum
significantly higher rate of inadequate pain relief, suggesting that
This outcome was not reported in any of the studies. there may be a trade-off between satisfactory analgesia during the
second stage and an increased risk of instrumental delivery. This
was also the study with the highest overall instrumental delivery
(14) Incidence of sexual problems postpartum rates.
This outcome was not reported in any of the studies. The management of women with epidural analgesia and the type
and dosage of drug varies between hospitals, countries and over
time. All the studies in this review used different epidural analgesia
A priori subgroup analyses protocols. Although our subgroup analyses did not show any sig-
nificant differences, the effect of discontinuing epidural analgesia
late in labour may not be the same under all conditions. The last
high-quality trial (Chestnut 1990) was undertaken 14 years ago,
(1) By parity
and practices have changed since then. Second stage management
All study participants were having their first baby so this subgroup strategies which have the potential to reduce instrumental deliv-
analysis was not undertaken. ery rates among women with epidural analgesia include the use of
Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia 6
(Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
an upright position, delayed pushing, and no upper limit on the Implications for practice
length of second stage in the absence of maternal or fetal distress
At present there is insufficient evidence to support the hypothesis
and as long as progress is being made.
that discontinuing epidural analgesia reduces the incidence of in-
strumental delivery, but there is evidence that it increases women’s
The practice of discontinuing epidural analgesia for the second pain. Whenever possible, women should be informed of the risks
stage of labour is widespread, and many women may be experi- and benefits of discontinuing epidural analgesia, and encouraged
encing increased pain during their second stage of labour when to participate in the decision of whether to discontinue or not.
there is no evidence of any benefit, and there is the possibility of an
increased risk of low Apgar score at one minute. Whilst an increase Implications for research
in pain may be acceptable to some women if accompanied by a
A large, well conducted randomised controlled trial is required to
reduced risk of instrumental delivery or other adverse outcome,
determine whether discontinuing epidural analgesia reduces the
women are unlikely to find it acceptable when not accompanied
incidence of instrumental delivery, as well as being effective, safe
by any benefit. The effect of discontinuing epidurals on women’s
and acceptable to women and staff.
satisfaction with labour care is unknown as no study reported this
outcome.
ACKNOWLEDGEMENTS
Thanks to Sonja Henderson, Zarko Alfirevic and Lynn Hampson
AUTHORS’ CONCLUSIONS for their support in the production of this review.
REFERENCES
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Indicates the major publication for the study
Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia 8
(Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
CHARACTERISTICS OF STUDIES
Chestnut 1987a
Methods Centrally randomised according to a table of random numbers. Caregivers and participants blinded to
study solution
Participants Nulliparous women with term (>= 36 weeks) singleton fetuses of vertex presentation who were receiving a
continuous epidural infusion of 0.75% lidocaine. Exclusion criteria: women with pre-eclampsia, insulin-
dependent diabetes, intrauterine growth retardation or chorioamnionitis. 65 women enrolled, 12 excluded
Interventions When the cervix was dilated by 8 or more centimetres, the syringe containing 0.75% lidocaine was
substituted with a study solution. In the study group (n = 27) this contained saline and in the control
group (n = 26) this contained 0.75% lidocaine
Outcomes Instrumental delivery, oxytocin augmentation, fetal malposition, caesarean section, inadequate pain relief,
Apgar scores < 7 at 1 and 5 mins, umbilical arterial pH, duration of 1st and 2nd stage of labour
Risk of bias
Chestnut 1987b
Methods Centrally randomised according to a table of random numbers. Caregivers and participants blinded to
study solution
Participants Healthy nulliparous women with term (>= 36 weeks) singleton fetuses of vertex presentation who were
receiving a continuous epidural infusion of 0.125% bupivacaine. Exclusion criteria: women with pre-
eclampsia or insulin-dependent diabetes. 110 women enrolled, 18 excluded
Interventions When the cervix was dilated by 8 or more centimetres, the syringe containing 0.125% bupivacaine was
substituted with a study solution . In the study group (n = 46) this contained saline and in the control
group (n = 46) this contained 0.125% bupivacaine
Outcomes Instrumental delivery, oxytocin augmentation, fetal malposition, caesarean section, inadequate pain relief,
Apgar scores < 7 at 1 and 5 mins, umbilical arterial pH, duration of 1st and 2nd stage of labour
Notes
Risk of bias
Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia 9
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Chestnut 1987b (Continued)
Chestnut 1990
Methods Centrally randomised according to a table of random numbers. Caregivers and participants blinded to
study solution
Participants Healthy nulliparous women with term (>= 36 weeks) singleton fetuses of vertex presentation who were
receiving a continuous epidural infusion of 0.0625% bupivacaine and 0.0002% fentanyl. Exclusion
criteria: women with pre-eclampsia or insulin-dependent diabetes. 75 women enrolled, 12 excluded
(including 2 in each group excluded postrandomisation for protocol violation)
Interventions When the cervix was dilated by 8 or more centimetres, the syringe containing 0.0625% bupivacaine 0.
0002% fentanyl was substituted with the study solution. In the study group (n = 34) this contained saline
and in the control group (n = 29) this contained bupivacaine -0.0002% fentanyl
Outcomes Instrumental delivery, oxytocin augmentation, fetal malposition, caesarean section, inadequate pain relief,
Apgar scores < 7 at 1 and 5 mins, umbilical arterial pH, duration of 1st and 2nd stage of labour
Notes
Risk of bias
Johnsrud 1988
Participants Nulliparous women with term (exceeding 37 weeks) singleton fetuses of vertex presentation who were
receiving a continuous epidural infusion of 2.5 mg/ml bupivacaine. 200 women enrolled, 20 excluded,
unclear whether pre or postrandomisation
Interventions In the study group (n = 90) the epidural infusion was discontinued in 2nd stage whilst the same epidural
infusion was continued in the control group (n = 90)
Outcomes Instrumental delivery, fetal malposition, inadequate pain relief, Apgar scores < 8 at 1 and 5 mins, duration
of 1st and 2nd stage of labour
Notes Oxytocin augmentation given to all women. Active pushing time was not to exceed 1 hour
Risk of bias
Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia 10
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Johnsrud 1988 (Continued)
Luxman 1996
Participants Primiparous women in spontaneous labour with uncomplicated pregnancies at term and receiving epidural
top-ups of 0.25% bupivacaine. 74 women enrolled, 4 postrandomisation exclusions
Interventions The study group (n = 37) was not given top-ups after cervical dilatation had reached 8 centimetres, whilst
the control group (n = 37) continued to receive top-ups until delivery
Outcomes Instrumental delivery, oxytocin augmentation, caesarean section, mean Apgar scores at 1 and 5 mins, rate
of dilatation, duration of 2nd stage of labour. No measure of pain relief reported
Notes Amniotomy performed on all women who did not present to the labour ward with spontaneous rupture
of membranes
Risk of bias
mins: minutes
Phillips 1983 This study was excluded because in 16 of the 59 women (27%), the reason for the epidural was obstetric or medical
rather than for analgesia
Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia 11
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DATA AND ANALYSES
No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size
1 Instrumental delivery 5 462 Risk Ratio (M-H, Fixed, 95% CI) 0.84 [0.61, 1.15]
2 Instrumental delivery by 5 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
subgroup analysis
2.1 Continuous infusion 4 388 Risk Ratio (M-H, Fixed, 95% CI) 0.81 [0.58, 1.12]
2.2 Intermittant bolus 1 74 Risk Ratio (M-H, Fixed, 95% CI) 1.2 [0.40, 3.59]
2.3 LA alone 4 399 Risk Ratio (M-H, Fixed, 95% CI) 0.85 [0.62, 1.18]
2.4 LA + opioid 1 63 Risk Ratio (M-H, Fixed, 95% CI) 0.71 [0.24, 2.09]
3 Caesarean section 4 282 Risk Ratio (M-H, Fixed, 95% CI) 0.98 [0.43, 2.25]
4 Caesarean section by subgroup 4 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
analysis
4.1 Continuous infusion 3 208 Risk Ratio (M-H, Fixed, 95% CI) 0.98 [0.39, 2.46]
4.2 Intermittant bolus 1 74 Risk Ratio (M-H, Fixed, 95% CI) 1.0 [0.15, 6.73]
4.3 LA alone 3 219 Risk Ratio (M-H, Fixed, 95% CI) 1.11 [0.46, 2.68]
4.4 LA + opioid 1 63 Risk Ratio (M-H, Fixed, 95% CI) 0.29 [0.01, 6.76]
5 Spontaneous vaginal delivery 4 282 Risk Ratio (M-H, Fixed, 95% CI) 1.11 [0.95, 1.30]
6 Spontaneous vaginal delivery by 4 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
subgroup analysis
6.1 Continuous infusion 3 208 Risk Ratio (M-H, Fixed, 95% CI) 1.18 [0.97, 1.45]
6.2 intermittant bolus 1 74 Risk Ratio (M-H, Fixed, 95% CI) 0.97 [0.77, 1.22]
6.3 LA alone 3 219 Risk Ratio (M-H, Fixed, 95% CI) 1.11 [0.92, 1.34]
6.4 LA + opioid 1 63 Risk Ratio (M-H, Fixed, 95% CI) 1.12 [0.88, 1.44]
7 Duration of 2nd stage 3 203 Mean Difference (IV, Fixed, 95% CI) -5.80 [-12.91, 1.30]
8 Duration of 2nd stage by 3 Mean Difference (IV, Fixed, 95% CI) Subtotals only
subgroup analysis
8.1 Continuous infusion 2 133 Mean Difference (IV, Fixed, 95% CI) -15.12 [-35.42, 5.
18]
8.2 Intermittant bolus 1 70 Mean Difference (IV, Fixed, 95% CI) -4.5 [-12.09, 3.09]
9 Fetal malposition 4 388 Risk Ratio (M-H, Fixed, 95% CI) 1.36 [0.73, 2.56]
10 Fetal malposition by subgroup 4 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
analysis
10.3 LA alone 3 325 Risk Ratio (M-H, Fixed, 95% CI) 1.38 [0.70, 2.71]
10.4 LA + opioid 1 63 Risk Ratio (M-H, Fixed, 95% CI) 1.28 [0.23, 7.14]
11 Inadequate pain relief 4 384 Risk Ratio (M-H, Fixed, 95% CI) 3.68 [1.99, 6.80]
12 Inadequate pain relief by 4 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
subgroup analysis
12.3 LA alone 3 321 Risk Ratio (M-H, Fixed, 95% CI) 3.44 [1.81, 6.53]
12.4 LA + opioid 1 63 Risk Ratio (M-H, Fixed, 95% CI) 5.97 [0.78, 45.73]
13 Apgar score < 7 or < 8 at 1 4 388 Risk Ratio (M-H, Fixed, 95% CI) 1.55 [0.94, 2.55]
minute
14 Apgar score < 7 or < 8 at 1 4 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
minute by subgroup analysis
14.3 LA alone 3 325 Risk Ratio (M-H, Fixed, 95% CI) 1.77 [1.03, 3.03]
14.4 LA + opioid 1 63 Risk Ratio (M-H, Fixed, 95% CI) 0.64 [0.16, 2.63]
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
15 Apgar score < 7 at 5 minutes 3 208 Risk Ratio (M-H, Fixed, 95% CI) 3.92 [0.45, 34.21]
16 Umbilical arterial pH 3 208 Mean Difference (IV, Fixed, 95% CI) -0.01 [-0.03, 0.01]
17 Umbilical arterial pH by 3 Mean Difference (IV, Fixed, 95% CI) Subtotals only
subgroup analysis
17.3 LA alone 2 145 Mean Difference (IV, Fixed, 95% CI) -0.02 [-0.05, 0.00]
17.4 LA + opioid 1 63 Mean Difference (IV, Fixed, 95% CI) 0.01 [-0.02, 0.04]
Review: Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia
Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia 13
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.2. Comparison 1 Discontinued versus continued, Outcome 2 Instrumental delivery by subgroup
analysis.
Review: Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia
1 Continuous infusion
Chestnut 1987a 9/27 8/26 13.9 % 1.08 [ 0.49, 2.38 ]
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.3. Comparison 1 Discontinued versus continued, Outcome 3 Caesarean section.
Review: Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia
Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia 15
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.4. Comparison 1 Discontinued versus continued, Outcome 4 Caesarean section by subgroup
analysis.
Review: Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia
1 Continuous infusion
Chestnut 1987a 1/27 0/26 6.3 % 2.89 [ 0.12, 67.96 ]
Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia 16
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.5. Comparison 1 Discontinued versus continued, Outcome 5 Spontaneous vaginal delivery.
Review: Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.6. Comparison 1 Discontinued versus continued, Outcome 6 Spontaneous vaginal delivery by
subgroup analysis.
Review: Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia
1 Continuous infusion
Chestnut 1987a 17/27 18/26 30.0 % 0.91 [ 0.62, 1.34 ]
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.7. Comparison 1 Discontinued versus continued, Outcome 7 Duration of 2nd stage.
Review: Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia
Mean Mean
Study or subgroup Discontinued Continued Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia 19
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.8. Comparison 1 Discontinued versus continued, Outcome 8 Duration of 2nd stage by subgroup
analysis.
Review: Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia
Mean Mean
Study or subgroup Discontinued Continued Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Continuous infusion
Chestnut 1987a 27 76 (48) 26 73 (63) 45.1 % 3.00 [ -27.24, 33.24 ]
Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia 20
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.9. Comparison 1 Discontinued versus continued, Outcome 9 Fetal malposition.
Review: Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia
Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia 21
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.10. Comparison 1 Discontinued versus continued, Outcome 10 Fetal malposition by subgroup
analysis.
Review: Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia
3 LA alone
Chestnut 1987a 2/27 2/26 15.6 % 0.96 [ 0.15, 6.34 ]
Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia 22
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.11. Comparison 1 Discontinued versus continued, Outcome 11 Inadequate pain relief.
Review: Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.12. Comparison 1 Discontinued versus continued, Outcome 12 Inadequate pain relief by
subgroup analysis.
Review: Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia
3 LA alone
Chestnut 1987a 12/27 6/26 60.4 % 1.93 [ 0.85, 4.37 ]
Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia 24
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.13. Comparison 1 Discontinued versus continued, Outcome 13 Apgar score < 7 or < 8 at 1
minute.
Review: Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.14. Comparison 1 Discontinued versus continued, Outcome 14 Apgar score < 7 or < 8 at 1
minute by subgroup analysis.
Review: Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia
3 LA alone
Chestnut 1987a 9/27 1/26 5.7 % 8.67 [ 1.18, 63.69 ]
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.15. Comparison 1 Discontinued versus continued, Outcome 15 Apgar score < 7 at 5 minutes.
Review: Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia
Analysis 1.16. Comparison 1 Discontinued versus continued, Outcome 16 Umbilical arterial pH.
Review: Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia
Mean Mean
Study or subgroup Discontinued Continued Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Chestnut 1987a 27 7.22 (0.07) 26 7.24 (0.07) 30.4 % -0.02 [ -0.06, 0.02 ]
Chestnut 1987b 46 7.21 (0.12) 46 7.24 (0.06) 28.7 % -0.03 [ -0.07, 0.01 ]
Chestnut 1990 34 7.27 (0.06) 29 7.26 (0.07) 40.9 % 0.01 [ -0.02, 0.04 ]
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.17. Comparison 1 Discontinued versus continued, Outcome 17 Umbilical arterial pH by
subgroup analysis.
Review: Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia
Mean Mean
Study or subgroup Discontinued Continued Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
3 LA alone
Chestnut 1987a 27 7.22 (0.07) 26 7.24 (0.07) 51.4 % -0.02 [ -0.06, 0.02 ]
Chestnut 1987b 46 7.21 (0.12) 46 7.24 (0.06) 48.6 % -0.03 [ -0.07, 0.01 ]
WHAT’S NEW
Last assessed as up-to-date: 28 October 2007.
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Date Event Description
HISTORY
Protocol first published: Issue 4, 2003
Review first published: Issue 4, 2004
29 October 2006 New search has been performed Search updated. No new trial reports identified.
9 August 2004 New citation required and conclusions have changed Substantive amendment
CONTRIBUTIONS OF AUTHORS
Christine Roberts was responsible for the project proposal and was the primary author for the protocol. Christine Roberts and Siranda
Torvaldsen independently assessed trials for inclusion and extracted the data. Siranda Torvaldsen was responsible for revisions of the
protocol, data entry, analysis and was the primary author for the review. Jane Bell provided valuable Review Manager expertise. Christine
Roberts, Siranda Torvaldsen, Jane Bell and Camille Raynes-Greenow all gathered background information and provided editorial
assistance.
DECLARATIONS OF INTEREST
None known.
SOURCES OF SUPPORT
Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia 29
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Internal sources
• Centre for Perinatal Health Services Research, University of Sydney, Australia.
External sources
• Commonwealth Department of Health and Ageing (JC Bell), Australia.
• National Health and Medical Research Council (S Torvaldsen, CL Roberts and CH Raynes-Greenow’s positions are wholly or
partially funded), Australia.
INDEX TERMS
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Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.