Corresponding Author
Dr. med. univ. Felix Kraft
Department of Anaesthesia, Intensive Care Medicine and Pain Medicine,
Medical University of Vienna
Währinger Gürtel 18-20
A-1090 Vienna, Austria
Tel: +43 1 40400 41020
Fax: +43 1 40400 41040
E-Mail: felix.kraft@meduniwien.ac.at
Word count: 3358/3500 (excl. acknowledgements and references), Abstract:
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Figures: 1, Tables: 3
Running title: Epidural analgesia and neonatal short-term outcome in
Austria
Abstract
Objective To investigate the use and association of epidural
analgesia (EA) on neonatal short-term outcome in vaginal childbirth at
term of primiparous parturients.
Design Retrospective cohort study.
Setting Data of the National Birth Registry of Austria between
2008 and 2017.
Population Primiparous women with spontaneous vaginal birth at
term of singleton pregnancies in Austria.
Methods Linear and logistic regression models to investigate an
association of epidural analgesia on short-term neonatal outcome in
propensity score adjusted cohorts.
Main outcome measures : Short-term morbidity assessed by
arterial cord pH and base excess. Secondary outcomes were admission to a
neonatal intensive care unit, APGAR scores, and perinatal mortality.
Results: Of 247 536 included deliveries, 52 153 received EA
(21%). Differences in pH (7.24 vs. 7.25; 97.5% CI -0.0066 to -0.0047)
and BE (-5.89 ± 3.2 mmol/l vs. ‑6.15 ± 3.2 mmol/l; 97.5% CI 0.32 to
0.40) with EA could be shown. APGAR score at 5 minutes below 7 was more
frequent with EA (OR 1.45; 95% CI 1.29 to 1.63). Admission to a
neonatological intensive care unit occurred more often with EA (4.7%
vs. 3.4%) with an OR for EA of 1.2 (95% CI 1.14 to 1.26). EA was not
associated with perinatal mortality (OR 1.33; 95% CI 0.79 to 2.25).
Conclusions EA showed no relevant association with short-term
morbidity. Higher rates of NICU admission and APGAR score after 5
minutes below 7 were observed with EA. Overall use of EA in Austria is
low, and investigation of causes may be indicated.
Keywords
Epidural analgesia, vaginal birth, neonatal outcome
Funding
No funding, financial support or sponsorship was received.
Tweetable abstract
No association of epidural analgesia on short-term neonatal outcome in
primiparous women with vaginal birth at term.
Introduction
Epidural analgesia (EA) represents the gold standard for pain control
during the first and second stage of labour.1 There
are indications that significant pain during childbirth is associated
with an increased incidence of postpartum depression or posttraumatic
stress. In deliveries without analgesia, mothers showed decreased
cognitive function on the first day after delivery compared with women
who received opioid
analgesia.2Compared with systemic opioid analgesia, EA led to higher rates of pain
relief satisfaction and less additional analgesic
requirements.3 For fathers attending an intensely
painful delivery, this experience was humbling and stressful, leading to
anxiety and a feeling of helplessness. The use of EA remarkedly
ameliorated the situation and enabled the partners to become involved
and supportive.4
Furthermore, EA leads to a reduction of vegetative stress responses,
which can be essential in at-risk women with pre‑existing cardiovascular
comorbidities, obesity, or
preeclampsia.5However, inadvertent intrathecal or intravascular placement of the
epidural catheter, epidural hematoma or abscesses may lead to life
threatening complications, cardiorespiratory arrest or significant
neurological injuries and, though rare, must be discussed with the
patient.6
In addition, when doses of local anesthetics are inadequately high (i.e.
epidural bupivacaine >0.125% or ropivacaine
>0.17%), EA may be associated with a prolonged duration of
labour, and elevated rates of instrumental or assisted
deliveries.3,7In about 20% of deliveries with EA, maternal aseptic hyperthermia
occurs.8 This epidural-related maternal fever may
worsen the newborns’ outcome by an increased risk for hypotension,
assisted ventilation or treatment with antibiotics for suspected
neonatal
sepsis.9,10EA was associated with increased neonatal morbidity in means of APGAR
score at 5 minutes <7 in a population-based register study,
however information on concomitant circumstances with potential
influence on outcome were limited.11 Heart rate
changes in neonates after EA are
described.12Still, the causal association of EA and neonatal morbidity remains
unclear.
The National Birth Registry of Austria reported 15.5% EA use for
vaginal deliveries in 2017.13 A recently published
comprehensive national survey on obstetric anesthesia practice in
Austria revealed rates <30% of EA use in 86% of the
responding hospitals. As this was a subjective survey in health care
providers, no conclusions on feto-maternal health care could be
drawn.14
The objective of this study was to retrospectively analyse data from
2008-2017 of the Austrian National Birth Registry to assess quality of
care and association of EA with neonatal short-term outcome in women
undergoing labour and vaginal delivery at term.
Methods