The effect of epidural analgesia on rates of episiotomy use and episiotomy extension in an inner-city hospital

Effects of combined spinal epidural labor analgesia on episiotomy: a retrospective cohort study

BACKGROUND

According to some published studies, neuraxial analgesia may be associated with prolonged labor and an increased risk for instrumental vaginal delivery. However, its effects on episiotomy are unknown. This study aimed to examine the incidence of episiotomy with and without combined spinal-epidural analgesia (CSEA) during labor.

METHODS

This was a retrospective cohort study, in which the computerized medical records of nulliparous women with singleton, cephalic and live births were reviewed and women with and without CSEA were matched based on their propensity scores. Univariate and multivariate analyses were used to examine the association between CSEA and the incidence of episiotomy during vaginal delivery.

RESULTS

In the cohort study with 11,994 vaginal deliveries, 5748 received CSEA and 6246 did not receive CSEA. 4116 CSEA women were successfully matched with 4116 Non-CSEA women. In the univariate analysis, the incidence of episiotomy was 47.4% in the CSEA group and 44.7% in the Non-CSEA group. However, after a multivariable logistic regression analysis, CSEA did not increase the risk of episiotomy (adjusted OR, 1.080; 95% confidence interval [CI], 0.988-1.180).

CONCLUSIONS

The use of CSEA during labor and vaginal delivery did not increase the risk of episiotomy.

Influence of the duration of the second stage of labor on the likelihood of obstetric anal sphincter injury

BACKGROUND

Duration of the second stage of labor has been suggested as an independent risk factor for clinically detectable obstetric anal sphincter injury in low-risk nulliparous women.

METHODS

A retrospective 5-year cohort study was conducted in a UK obstetrics center which included a high-risk delivery unit and a low-risk birthing center. The study included 4,831 nulliparous women with vertex-presenting, single, live-born infants at term, stratified according to spontaneous or instrumental delivery. Binary logistic regression models were used to examine the association between duration of second stage and sphincter injury.

RESULTS

Three-hundred twenty-five of 4,831 women (6.7%) sustained sphincter injuries. In spontaneously delivering women, no association between duration of the second stage and the likelihood of sphincter injury was recorded. Factors associated with increased likelihood of sphincter injury included older maternal age, higher birthweight, and Southeast Asian ethnicity. In contrast, for women undergoing instrumental delivery, a longer second stage was associated with an increased sphincter injury risk of 6 percent per 15 minutes in the second stage of labor before delivery.

CONCLUSIONS

For spontaneous vaginal deliveries, duration of the second stage of labor was not an independent risk factor for obstetric anal sphincter injury. The association between prolonged second stage and sphincter injury for instrumental deliveries is likely explained by the risk posed by the use of the instruments themselves or by delay in initiating instrumental assistance. Attempts to modify the duration of the second stage for prevention of sphincter injuries are unlikely to be beneficial and may be detrimental.

Trends in the medicalisation of childbirth in Flanders and the Netherlands

OBJECTIVE

in this paper we offer new insights about the medicalisation of childbirth by closely examining the trends in obstetric intervention rates in Flanders and the Netherlands and by considering the influence of contextual factors - including the organisation of the medical system, professional guidelines, and cultural ideas - on the way maternity care is delivered.

DESIGN

a comparative study using perinatal statistics from the National Perinatal Databases of the Netherlands and Flanders and historical and qualitative data about the organisation and culture of maternity care in each country.

SETTING AND PARTICIPANTS

in the Netherlands data are gathered from practices of the participating midwives, general practitioners and obstetricians. In Flanders the registration of data takes place in Flemish maternity units and independent midwifery practices.

MEASUREMENTS AND FINDINGS

in the Netherlands the home birth rate is still by far the highest in Europe and some interventions (e.g. caesarean section and epidural) are among the lowest. However, some perinatal statistics - such as in the use of epidural analgesia during labour - suggest an increasingly medical approach to birth in the Netherlands. Other trends in the Netherlands include an increasing use of inductions and augmentation in labour, and a decreasing number of births in primary care. The practice of home birth is being challenged by critical discussions in the popular media and 'scientific' debates among professionals. In Flanders, there have been some efforts to reduce medicalisation of childbirth, focussed on specific interventions such as induction and episiotomy.

KEY CONCLUSIONS

in recent years the obstetric intervention rates in Belgium and the Netherlands are slowly converging.

IMPLICATIONS FOR PRACTICE

because the lives of women, midwives, and obstetricians (among others) are significantly affected by patterns of medicalisation and de-medicalisation, it is important that we understand the drivers of the medicalising process.

Analgesia and Anesthesia in Labor

Whether given as an epidural, spinal, or combination, regional anesthesia is an integral part of obstetrics in the United States. A variety of drugs and dosages are used in various combinations, with no one protocol exceeding others in terms of efficacy and safety. The availability of anesthesia and analgesia has had an extraordinary impact on the field of obstetrics in the twentieth century. Knowledge of the techniques and medications used, their potential toxicities, and effects on the labor process itself can only enhance obstetricians' management of the parturient in labor.