European Journal of Obstetrics & Gynecology
and Reproductive Biology 59 Supp!. (1995) S31-S33
Effects of epidural analgesia on the progress of labor and the mode of
delivery
M. Finster
Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, USA
The potential effects of epidural analgesia on the
progress of labor and the incidence of operative or
instrumental delivery has been a subject of lasting
controversy, particularly between obstetricians and
anesthesiologists. This controversy is difficult to resolve
since it is almost impossible to devise fully randomized,
prospective studies comparing different modes of pain
relief during the first stage of labor. There is no lack of
retrospective reviews. Most of them indicate that epi-
dural analgesia is associated with longer labors and/or
an increased incidence of forceps delivery or cesarean
section [1-7]. Similar results were reported in a few non-
randomized prospective studies [8-11], particularly
when epidural analgesia was started as early as in the
latent phase of labor [9]. Most authors tend to see a
casual relationship, even though, without randomiza-
tion, selection bias cannot be ruled out. Women having
a painful and protracted labor (malpresentation,
dystocia) are more likely to request epidural analgesia
than the less affected 'controls'. The same patients are
also more likely to require an operative or instrumental
delivery. Further, obstetricians are more prone to short-
en the second stage of labor with the use of forceps or
vacuum extractor when epidural analgesia is present.
There are several reports indicating that epidural anal-
gesia has no adverse effects on the progress of labor or
the woman's ability to deliver vaginally [12-17]. Par-
ticularly instructive among them are the studies showing
that introduction of an 'on demand' epidural service did
not increase the primary cesarean section rate [14-17].
Uterine activity usually has significant effect on the
progress of labor. Early studies showed that induction
of caudal or lumbar epidural analgesia resulted in a
transient decrease in uterine contractility, lasting 10-30
min [18-22]. In some of these reports this was attributed
to the addition of epinephrine to the local anesthetic sol-
ution [20,22]. Interestingly, the rate of cervical dilation
was not affected by the temporary decrease in uterine
activity [18,20]. In another study, uterine activity was
not altered by induction of epidural analgesia so long as
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the supine position was avoided [23], thus preventing
aortocaval compression, which is known to reduce
uterine contractility [24]. Administration of epidural
analgesia may also lead to an increase in uterine activity,
particularly an elevation of basal tone, and prolonged
decelerations of the fetal heart [25].
The most recent investigations have centered on the
effects of epidural analgesia on the duration of the sec-
ond stage of labor and the incidence of instrumental
delivery. These were conducted in a prospective, rando-
mized way, since it is not considered unethical to discon-
tinue the analgesia once the uterine cervix has reached
full dilatation and the mother is encouraged to bear
down. With the use of bupivacaine 0.25%, given by in-
termittent top-up injections, maintenance of epidural
analgesia throughout labor did not prolong the second
stage or increase the forceps delivery rate by comparison
with patients in whom top-up injections were withheld
during the second stage of labor [26]. Similar results
were obtained with a continuous epidural infusion of
0.75% of lidocaine [27]. The duration of the second
stage of labor and the frequency of operative delivery
were similar in women receiving lidocaine throughout
labor and in those having normal saline substituted for
the local anesthetic after the uterine cervix reached 8 cm
dilatation. In contrast, a study involving continuous in-
fusion of bupivacaine 0.125%, to nulliparous women
showed that maintaining epidural analgesia beyond 8
cm cervical dilatation resulted in a prolongation of the
second stage of labor (124 ± 70 min vs. 94 ± 54 min in
the saline group) and an increased frequency of in-
strumental delivery (53% vs. 28%) [28]. Later on, the
same group of investigators reported that with the con-
tinuous epidural infusion of 0.0625% bupivacaine, with
0.0002% fentanyl, maintenance of analgesia beyond cer-
vical dilatation of 8 cm had no effect on the duration of
the second stage of labor or the incidence of instrumen-
tal delivery [29]. Thus reducing the concentration of
bupivacaine, made possible by the addition of fentanyl,
had a salutory effect on the woman's ability to achieve
S32 M. Finster / European Journal of Obstetrics & Gynecology and Reproductive Biology 59 Suppl. (1995) S31-S33
spontaneous vaginal delivery. With intermittent epi-
dural injections of bupivacaine 0.125%, the addition of
sufentanil 10-30 /Lg, significantly reduced the incidence
of instrumental deliveries (from 36 to 24%) [30]. The
authors attributed this to the prolongation of the block
and reduced local anesthetic requirement with the addi-
tion of sufentanil.
The only study in which the effects of premature rup-
ture of membranes (PROM) on the incidence of
dystocia and instrumental delivery were evaluated show-
ed that these complications were more frequent among
nulliparous women with PROM than among those in
whom contractions preceded PROM [31]. This was in-
dependent of the choice of analgesia used during labor
and the authors concluded that any study which aims to
examine the effect of epidural analgesia on the outcome
of labor should include PROM as a bias factor.
Another serious bias may be introduced by the
patient's choice of service. At least one study revealed a
marked difference in cesarean section rate among
nulliparous women attending clinic versus private ser-
vices [32]. The use of epidural analgesia was similar in
both services (approximately 42%), but the cesarean sec-
tion rate was approximately 5% among the clinic pa-
tients compared with approximately 17% for the private
patients. Failure to progress was diagnosed in 0.5% and
14% of clinic and private patients, respectively.
Very recently published papers indicate that some
researchers were able to conduct prospective, rando-
mized studies comparing the effects of epidural conduc-
tion blockade with systemic narcotic analgesia [33-35].
The results of one are startling. Analgesia was begun at
cervical dilatation of approximately 4 cm. The group
receiving epidural analgesia had a significant prolonga-
tion of the first and second stages oflabor [33]. Further,
epidural analgesia was associated with a significant
increase in malposition and cesarean delivery occurred
more frequently in the epidural group (25% vs. 2.2% in
the narcotic group), primarily due to a higher incidence
of dystocia.
These results are contradicted by two other studies in
which patients were randomized to receive epidural
bupivacaine at a cervical dilatation of at least 3 cm but
less than 5 cm, or intravenous nalbuphine followed by
epidural bupivacaine only after the cervix was at least 5
cm dilated [34,35]. There were no differences between
groups in the duration of labor, in the incidence of
malposition, and in the incidence of instrumental or op-
erative delivery. The same results were obtained in a
group of nulliparous women receiving oxytocin [34] and
in another group who were in spontaneous labor [35].
In summary, the available data indicate that the
effects of epidural analgesia may vary, depending on the
timing and extent of the block, position of the patient,
the choice and concentration of local anesthetic, and the
addition of epinephrine or an opioid. Finally, premature
rupture of membranes and the choice of obstetrical ser-
vice may be the most important factors affecting the
course of labor and delivery.
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