Ausr NZ J Obsrer Gynaecol 1991; 31: 3: 227

Influence of Epidural Anaesthesia on the Course of Labour in Patients with Anteparturn Fetal Death Samuel Lurie MD*, Isaac Blickstein MD*, Michael Feinstein MD*, Avi Matzkel MD*, Tiberiu Ezri MDf and David Soroker MDt Departments of *Obstetrics and Gynaecology, and fAnaesthesiology, Kaplan Hospital, Rehovot, Israel (Affiliated to the Medical School of the Hebrew University and Hadawah, Jerusalem)

Summary: The course of labour in 22 patients with antepartum fetal death who received epidural anaesthesia was evaluated as compared to 22 controls matched for parity and gestational age, who received narcotic pain relief. Both groups had similar preinduction cervical dilatation and the induction was performed by amniotomy and oxytocin infusion. The mean first stage of labour was 5.4 hours in the epidural group, and 8.7 hours in the controls (p = 0.0192). The mean cervical dilatation rate was 3.3 cm/hour and 1.0crn/hour respectively (p = 0.0142). The second stage was similar in both groups. We conclude, that parturients receiving epidural anaesthesia may benefit both emotionally and physically from excellent pain relief and a shorter delivery process when going through the distressing experience of delivering a dead fetus. The emotional support of a mother with fetal demise is one of the cardinal points in management of antepartum fetal death. Adequate pain relief and rapid progression of labour may minimize the psychological distress of patients during the induction and the conduct of labour. In addition to the emotional support, the treatment of antepartum fetal death should be aimed at rapid termination of pregnancy, thus reducing maternal mortality and morbidity (1). It is generally accepted that epidural anaesthesia provides safe and effective pain relief and does not prolong or interfere with the normal progress of labour (2). In fact, it may shorten the first and second stages of labour by improving both the strength and frequency of uterine contractions (3,4). On the other hand, epidural anaesthesia has been reported to be associated with prolonged second stage of labour and increased frequency of instrumental delivery (5). Moreover, the risks of coagulopathy and intrauterine infection with septicaemia are relative contraindications to epidural anaesthesia in delivery of a dead fetus. The intention of this study was to evaluate the influence of epidural anaesthesia on the course of labour complicated by antepartum fetal death.

METHODS This was a self-selection study in which patients with antepartum fetal death were offered a choice of epidural anaesthesia or parenteral pethidine. We excluded patients with contraindications to epidural anaesthesia such as suspected infection (septicaemia or infection Address for correspondence: S. Lurie, Department Obstetrics and Gynecology, Kaplan Hospital, 76100 Rehovot, Israel.

near the site of injection), coagulation abnormality and anatomical abnormality (fused spine, spina bifida, severe scoliosis). During the study period (January, 1984 to June, 1990), 22 patients (13 nulliparous and 9 parous) with antepartum fetal death after 28 weeks’ gestation (mean 34.6) chose to receive epidural anaesthesia. During this period 121 patients with pregnancies complicated by antepartum fetal death delivered receiving continuous intravenous infusion of pethidine (50 mglhour) combined with promethazine (12.5 mg/hour). We selected a comparison group of 22 patients with antepartum fetal death of similar parity (13 nulliparous and 9 parous) and similar gestational age (mean 34.6 weeks). The diagnosis of fetal death was confirmed by sonography and all fetuses were in vertex presentation. Coagulopathy was excluded in all patients. A prophylactic preloading with 1,OOO to 1,500 mi of Ringer lactate solution was carried out rapidly prior to administration of the epidural anaesthesia. The block was performed between either the L2-L3 or L3-LA space with the patient in a sitting position. We used 10 ml of 2% lignocaine. A test dose using 2 mi of the solution was administered, followed by the insertion of a polyethylene catheter. The subsequent top-ups were given using 10 ml of 0.35% bupivacaine without adrenaline, or 10 ml of 2% lignocaine. Labour was induced in both groups by amniotomy and oxytocin infusion with increments of 0.5 milliunits/ minute every 10 to 15 minutes until the appearance of regular (3 per 10 minutes) uterine contractions. Both groups received a similar amount of oxytocin. The epidural anaesthesia was begun before induction of labour, while the narcotic agent was administered only when the patient asked for pain relief. The third stage of labour was similarly managed in both groups. We

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TabIe 1. Data on Course of Labour (Mean i SD) Epidural group Dilatation of cervix at amniotomy (cm) Dilatation rate (cmlhr) First stage of labour (hr) Second stage of labour (min)

Pethidine group

p value

2.3 rt. 0.9 2.6 T 2.0 NS 3.3 t_ 4.1 1.0 k 0.7 0.0142 5.4 rt. 4.5 8.7 rt. 4.7 0.0192 NS 33.2 k 28.0 33.2 _t 16.8

NS = not significant

allowed spontaneous placental delivery unless haemorrhage occurred or when the placenta was not expelled within 30 minutes of the infant's birth. The statistical analysis was done using the Student's t-test: p ( 0.05 was considered statistically significant.

RESUL'IS The labour characteristics of both groups are shown in table 1. The cervical dilatation rate was significantly faster (p = 0.0142) in the epidural group, resulting in a significantly shorter first stage (p = 0.0192), while the duration of the second stage was similar in both groups. All patients except one had spontaneous vaginal deliveries. One patient in the epidural group was delivered by vacuum extraction. After delivery 5 patients in the epidural group underwent manual removal of the placenta. In the pethidine group 5 patients needed postpartum general anaesthesia: 3 for removal of the placenta and 2 for exploration of the uterus because of postpartum haemorrhage. No complications associated with epidural anaesthesia were observed. DISCUSSION The management of pregnancies with fetal demise is a continuing obstetric challenge. Although most patients will eventually go into spontaneous labour, the emotional stress imposed upon the woman carrying a dead fetus, the dangers of possible coagulopathy, and the advent of effective methods of labour induction have increased the desirability of early delivery (6). Our data show that epidurai anaesthesia in addition to excellent pain relief provides an advantage of significantly shorter induction to delivery interval. The data show that patients under epidural anaesthesia have shorter first stages due to faster progression of labour when compared to patients with similar preinduction dilatation of the cervix who received narcotic pain relief. The dynamics of labour under epidural anaesthesia in patients with fetal demise have not been previously evaluated. Our comparative study demonstrated a

shorter duration of labour in patients with dead fetuses delivered with epidural anaesthesia. The mean duration of labour complicated by antepart um fetal death (APFD) as published previously and in our study was between 7.1 and 9.9 hours (7,8). Our results in patients complicated by APFD, who received epidural anaesthesia revealed a mean first stage of 5.4 hours and a mean second stage of 33.2 minutes. Our results demonstrate a significant decrease in the duration of labour when epidural anaesthesia was used, solely due to shortening of the first stage of labour. An important observation is that in the second stage there was no significant difference between the epidural and the control groups. Whether this shorter delivery process was the result of the epidural anaesthesia or zealous use of oxytocin or both was not evident. However, based on the data related to epidural anaesthesia during labour (2-4) and our comparison to the pethidine group, it may be suggested that epidural anaesthesia is important in shortening the induction-delivery interval. In addition, postpartum procedures, needed in about 25% of cases in our series, may be performed under epidural anaesthesia without an additional anaesthetic Furthermore, epidural anaesthesia may convert abnormal uterine contractions into a normal contraction pattern (4). I t may reduce the emotional and perhaps catecholamine levels resulting in regular contractions and it should have no effect on the third stage of labour. We conclude, that parturients receiving epidural anaesthesia may benefit both emotionally and physically from excellent pain relief and a shorter delivery process when going through the distressing experience of delivering a dead fetus. ReJemnces I . Kuhn W. Rath W (Us). International colloquvon thc manapmcnt of intrauterinefetal death. Int J Ciynecol Obstet 19117: 2!: IRS-IY7. 2. Cheek 1G.Gutrhe BB. Epidural analgesia for lahour and boginal delivery. Clinical Obstct Gynesol 19R7: 30: 515-52Y. 3. Phillips KC.Thomas TA. Second stage of labour with o r without extradural analgesia. Anaesthesia 19113; 311: 972.976. 4. Moir D. Wilocks J. Management of incoordinated utcrinc action under continuous epidural analgesia. Br Med J IY67; 3: 3 % - 4 0 . 5. Chestnut DH. VandcWalker GE. Owen Ct.. ct al. The influence of continous epidural bupivacaine analgesia on the second rtage of labour, and method of delivery in nulliparous women. Anesthesiology 1987; 66: 774-780. 6. Cunningham GE MacDonald PC. Gant NF. Williams OhwtricT. 18th ed. Connecticut. Appleton & lange. 19x9 716. 7. Miranda JA. Herruzo AJ, Montoya F, ct al. Induc:lion of dead fetus labour with 15-(s)-methyl prostaglandin i 2 alpha. Int J Gynecol Obstet 1988; 2 6 209.212. 8. Rath W. Kuhn W. Cerbical ripening and induction of lahour h) intracervical and extra-amniotic prortaglandin gel application in cases of intrauterine fetal death. Int J Gynecol Obstet 19x5: 23: 387-394.

Influence of epidural anaesthesia on the course of labour in patients with antepartum fetal death.

The course of labour in 22 patients with antepartum fetal death who received epidural anaesthesia was evaluated as compared to 22 controls matched for...
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