BACKGROUND AND PURPOSE: 

• Steady increase in epidural use, especially  over the last 20 years  
• Anim-Somuah et al. (Cochrane Database Syst Rev., 2018) assessed the effectiveness and safety of all types of epidural analgesia

METHODS: 

• Systematic review and meta-analysis 
• Database search of RCTs comparing all types of epidural with any form of pain relief not involving regional blockade, or no pain relief in labor 
• Two independent reviewers to minimize bias, extracted data, and check for accuracy  
• Participants: All pregnant women requesting pain relief 
• Determination of pain related outcomes was measured differently depending on the study (e.g. pain intensity scoring, maternal satisfaction with pain relief)  
• GRADE methods used for quality of evidence  
• Compared epidural (including combined spinal-epidural vs other types of pain management included placebo/no treatment or any other technique/therapy that did not involving regional blockade, including  
  • Hypnosis | Biofeedback | Intracutaneous or subcutaneous sterile water injection | Immersion in water | Aromatherapy | Relaxation techniques (yoga, music, audio) | Acupuncture or acupressure | Manual methods (massage, reflexology) | Transcutaneous electrical nerve stimulation (TENS) | Inhaled analgesia | Opioids | Non-opioid drugs | Local anaesthetic nerve blocks

RESULTS: 

• 40 RCTs were included, totaling 11,000 women 
• Compared to opioid, women receiving epidural analgesia had
  • Lower pain intensity with mean difference of -2.64 (95% CI, -4.56 to -0.73; low-quality evidence)  
  • Higher proportion of “excellent or very good” pain relief with average risk ratio (RR) of 1.47 (95% CI 1.03 to 2.08; low-quality evidence) 
  • Decreased need for additional pain relief methods with average RR of 0.10 (95% CI 0.04 to 0.25; P < 0.00001) 
  • More assisted vaginal birth with RR of 1.44 (95% CI 1.29 to 1.60; low-quality evidence), however this was negated when trials before 2005 were excluded  
• No clear difference in  
  • Cesarean section rates | Maternal long-term backache | Neonatal outcomes | Admission to neonatal ICU | Apgar scores 
• In epidural group, higher risk for  
  • Hypotension |Motor blockade |Fever | Urinary retention | Longer first and second stages of labor | Need for oxytocin augmentation  
• In epidural group, lower risk for  
  • Nausea | Respiratory depression 
• Compared to placebo or no treatment and acu-stimulation, epidural group had reduced pain reporting  

CONCLUSION: 

• Women receiving epidural analgesia for pain management in labour seemed to experience increased maternal satisfaction, and need for assisted vaginal birth no longer appeared as an outcome when adjusted for modern anesthesia approaches

Learn More – Primary Sources: 

Epidural versus non-epidural or no analgesia for pain management in labour

Related ObG Topics:

Does Epidural Anesthesia Impact the Second Stage of Labor?

Results of the BUMPES Trial: Sitting Up or Lying Down to Promote Vaginal Delivery with an Epidural in the 2nd Stage of Labor?

Epidural Timing: The Earlier the Better?

ACOG 2017 Guidelines: Who is a Candidate for a Vaginal Birth after Cesarean Section?