Correspondence
Regional Anesthesia and Analgesia for Labor and Delivery
N Engl J Med 2003; 348:1818-1820May 1, 2003
- Article
To the Editor:
In their interesting review article on regional analgesia for labor and delivery, Eltzschig et al. (Jan. 23 issue)1 state that the decision to receive any form of analgesia is personal and should be made by the patient in consultation with her care provider. Although the authors mention the many alternative methods of pain management and consider regional analgesia a safe and effective means of pain relief during labor, they mention only the administration of intrathecal opioids for analgesia after cesarean delivery, along with the associated high incidence of adverse effects and the need for prolonged postoperative monitoring. They do not discuss other options for the treatment of pain after cesarean delivery in women who are expected to recover quickly and to care for their babies within a few hours after surgery.
Studies have shown that oral, nonnarcotic analgesia after cesarean delivery provides satisfactory pain relief with no serious side effects and with no need for equipment that may restrict a woman's free access to her baby. We believe that women should be counseled about this simple, cheap, and satisfactory option.2,3
3 ReferencesPeter Jakobi, M.D.
Ido Solt, M.D.
Etan Z. Zimmer, M.D.
Rambam Medical Center, Haifa 31096, Israel
h_gruber@rambam.health. gov. il 1
Eltzschig HK ,Lieberman ES ,Camann WR . Regional anesthesia and analgesia for labor and delivery. N Engl J Med 2003;348:319-332
Full Text | Web of Science | Medline2
Jakobi P ,Weiner Z ,Solt I ,Alpert I ,Itskovitz-Eldor J ,Zimmer EZ . Oral analgesia in the treatment of post-cesarean pain. Eur J Obstet Gynecol Reprod Biol 2000;93:61-64
CrossRef | Web of Science | Medline3
Jakobi P ,Solt I ,Tamir A ,Zimmer EZ . Over-the-counter oral analgesia for postcesarean pain. Am J Obstet Gynecol 2002;187:1066-1069
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To the Editor:
We believe that it is important to stress two issues beyond those reviewed by Eltzschig et al. First, the concern about the effects of combined spinal–epidural analgesia on the fetal heart rate was reinforced by a meta-analysis by Mardirosoff et al.,1 who found that the risk of fetal bradycardia was significantly increased when intrathecal opioids were used for analgesia during labor (odds ratio, 1.8 [95 percent confidence interval, 1.0 to 3.1]). In addition, there is evidence that only high doses of intrathecal opioids result in problems with the fetal heart rate.2 When low doses of opioids are used in combination with local anesthetics for the initiation of spinal–epidural analgesia, such problems seem to be significantly less frequent.
Second, we believe it is important to emphasize that the provision of regional analgesia is not a generic procedure. The effect of recent developments (patient-controlled epidural analgesia, combined spinal–epidural analgesia, new local anesthetics, dilute solutions of local anesthetics, and the use of additives) on the outcome of labor has been insufficiently studied and may alter our views. Recent data hint that “modern” analgesia may improve the outcome. Nageotte et al.3 and the Comparative Obstetric Mobile Epidural Trial4 demonstrated that combined spinal–epidural analgesia and low-dose epidural anesthesia are associated with a higher rate of normal vaginal delivery because of a reduced incidence of assisted vaginal deliveries.
4 ReferencesMarc Van de Velde, M.D., Ph.D.
An Teunkens, M.D.
Eugène Vandermeersch, M.D., Ph.D.
University Hospital Gasthuisberg, 3000 Leuven, Belgium
marc.vandevelde@uz. kuleuven. ac. be 1
Mardirosoff C ,Dumont L ,Boulvain M ,Tramer MR . Fetal bradycardia due to intrathecal opioids for labour analgesia: a systematic review. BJOG 2002;109:274-281
CrossRef | Web of Science | Medline2
Van de Velde M ,Vercauteren M ,Vandermeersch E . Fetal heart rate abnormalities after regional analgesia for labor pain: the effect of intrathecal opioids. Reg Anesth Pain Med 2001;26:257-262
CrossRef | Web of Science | Medline3
Nageotte MP ,Larson D ,Rumney PJ ,Sidhu M ,Hollenbach K . Epidural analgesia compared with combined spinal-epidural analgesia during labor in nulliparous women. N Engl J Med 1997;337:1715-1719
Full Text | Web of Science | Medline4
Comparative Obstetric Mobile Epidural Trial (COMET) Study Group UK
CrossRef | Web of Science | Medline
To the Editor:
Eltzschig et al. suggest that the question of whether epidural analgesia for pain relief during labor increases the rate of cesarean deliveries remains unanswered. This view appears to be based mainly on the fact that most studies investigating this specific question have certain methodologic limitations. Yet neither a meta-analysis including 2369 patients in seven randomized trials1 nor a recent randomized study involving 453 patients2 nor a meta-analysis of nine sentinel-event studies including 37,753 patients3 showed any significant effect of epidural analgesia on the overall incidence of cesarean delivery. Another recent randomized trial (not mentioned in the review article) did not identify a significant increase in the rate of cesarean deliveries among 56 women with severe preeclampsia who received intrapartum epidural analgesia, as compared with 60 women who received patient-controlled intravenous opioid analgesia.4 Is it not time to reassure our patients that the selection of epidural analgesia during labor is very unlikely to have any obvious, clinically relevant effect on the risk of cesarean delivery?
4 ReferencesBernhard Zwissler, M.D.
Clinic of Anesthesiology, 80336 Munich, Germany
bernhard.zwissler@ana. med. uni-muenchen. de 1
Halpern SH ,Leighton BL ,Ohlsson A ,Barrett JFR ,Rice A . Effect of epidural vs parenteral opioid analgesia on the progress of labor: a meta-analysis. JAMA 1998;280:2105-2110
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Sharma SK ,Alexander JM ,Messick G , et al. Cesarean delivery: a randomized trial of epidural analgesia versus intravenous meperidine analgesia during labor in nulliparous women. Anesthesiology 2002;96:546-551
CrossRef | Web of Science | Medline3
Segal S ,Su M ,Gilbert P . The effect of a rapid change in availability of epidural analgesia on the cesarean delivery rate: a meta-analysis. Am J Obstet Gynecol 2000;183:974-978
CrossRef | Web of Science | Medline4
Head BB ,Owen J ,Vincent RD Jr ,Shih G ,Chestnut DH ,Hauth JC . A randomized trial of intrapartum analgesia in women with severe preeclampsia. Obstet Gynecol 2002;99:452-457
CrossRef | Web of Science | Medline
Author/Editor Response
Jakobi et al. raise the issue of alternatives to intrathecal opioids for pain relief after cesarean delivery; we agree that these drugs should be considered as alternatives. In addition, the use of oral analgesic agents, such as nonsteroidal antiinflammatory drugs, is now a common and effective adjunct to the use of neuraxial opioids, allowing for lower doses and resulting in a decreased rate of opioid-related side effects.
Van de Velde et al. raise the issue of the effect of the dose of medication used for combined spinal–epidural analgesia and the incidence of fetal bradycardia. Although high doses of opioids may be associated with an increase in the risk of fetal bradycardia, our review found that existing data were insufficient to permit any conclusion about whether the doses currently used for combined spinal–epidural analgesia contribute to an increase in the risk of fetal bradycardia as compared with epidural analgesia alone. As we noted, however, it is reassuring that no studies have found differences in neonatal outcome between women who received combined spinal–epidural analgesia and women who received traditional epidural analgesia. We also agree that recently introduced epidural techniques warrant further study. Although the studies cited by Van de Velde et al. did find a lower rate of instrument-assisted vaginal delivery with combined spinal–epidural analgesia and lower-dose epidural analgesia than with traditional epidural analgesia, most other randomized trials have not found such differences. In addition, both of those studies reported a high incidence of forceps-assisted deliveries (30 to 40 percent) in all groups studied.1,2 This high incidence limits the generalizability of these results and reinforces our observation that the magnitude of the association between regional analgesia during labor and obstetrical outcomes may be strongly influenced by local obstetrical practices.
In reply to Dr. Zwissler, the studies by Halpern et al., Sharma et al., and Segal et al. that he cites were all discussed in our article. We explain in the article that although sentinel-event studies do indicate that one can introduce an epidural-analgesia service without having an increase in the rate of cesarean deliveries, these studies cannot rule out significant effects on the rates of such deliveries in large subgroups. We also thank Dr. Zwissler for raising the timely issue of epidural analgesia in the setting of preeclampsia. We did not discuss this issue in our article, since we focused on pain relief for healthy parturient women.
2 ReferencesWilliam Camann, M.D.
Holger Eltzschig, M.D.
Ellice Lieberman, M.D., Dr.P.H.
Brigham and Women's Hospital, Boston, MA 02115
wcamann@partners.org 1
Nageotte MP ,Larson D ,Rumney PJ ,Sidhu M ,Hollenbach K . Epidural analgesia compared with combined spinal-epidural analgesia during labor in nulliparous women. N Engl J Med 1997;337:1715-1719
Full Text | Web of Science | Medline2
Comparative Obstetric Mobile Epidural Trial (COMET) Study Group UK
CrossRef | Web of Science | Medline
- Citing Articles (2)
Citing Articles
1
A. Malvasi, A. Tinelli, A. Brizzi, F. Greco, D. Celleno, R. Tinelli. (2009) Long-term epidural analgesia treatment in pre-eclamptic women: A preliminary trial. Journal of Obstetrics & Gynaecology 29:2, 114-118
CrossRef2
Melissa J. Krauss, Nhial Tutlam, Eileen Costantinou, Shirley Johnson, Diane Jackson, Victoria J. Fraser. (2008) Intervention to Prevent Falls on the Medical Service in a Teaching Hospital. Infection Control and Hospital Epidemiology 29:6, 539-545
CrossRef
