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: 248/250
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