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ORIGINAL RESEARCH |
From the Department of Maternal Fetal Medicine, Brigham & Women’s Hospital, Boston, Massachusetts.
Address reprint requests to: Julian N. Robinson, MD, MBBS, MRCOG Division of Maternal Fetal Medicine Department of Obstetrics and Gynecology Brigham and Women’s Hospital 75 Francis Street Boston, MA 02115 E-mail: jnrobinson{at}bics.bwh.harvard.edu
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Abstract |
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Methods: We studied 1942 consecutive, low-risk, term, vaginal deliveries in nulliparas, including spontaneous and induced labors, at a single institution from December 1994 to August 1995. The rate of third- and fourth-degree lacerations was compared for women who had and did not have epidural analgesia for labor-pain relief. Statistical significance was determined using 
2. Logistic regression analyses were used to evaluate associations while controlling for possible confounding variables.
Results: Overall rates of third- and fourth-degree lacerations were 10.8% (n = 210) and 3.4% (n = 63), respectively. Epidural analgesia was given to 1376 (70.9%) women. Among women who had epidurals, 16.1% (221 of 1376) had severe perineal lacerations compared with 9.7% (n = 55) of the 566 women who did not have epidurals (P < .001; odds ratio [OR] 1.8, 95% confidence interval [CI] 1.3, 2.4). When controlling for birth weight, use of oxytocin, and maternal age in logistic regression analysis, epidural remained a significant predictor of severe perineal injury (OR 1.4, 95% CI 1.0, 2.0). Epidural use is consistently associated with increased operative vaginal deliveries and consequent episiotomies, so we constructed a logistic regression model to evaluate whether the higher rates of those procedures were responsible for the effect of epidurals on severe perineal traumas. With operative vaginal delivery and episiotomy in the model, epidural was no longer an independent predictor of perineal injury (OR 0.9, 95% CI 0.6, 1.3).
Conclusion: Epidural analgesia is associated with an increase in the rate of severe perineal trauma because of the more frequent use of operative vaginal delivery and episiotomy.
Epidural analgesia has become popular in modern obstetric practice because of its excellent labor-pain relief. Investigators extensively have examined consequences of this anesthetic technique on courses of labor and methods of delivery. In a recent review, 102 manuscripts were analyzed on the subject.1 Despite the interest in its obstetric consequences, there have been few reports that evaluated possible interactions of regional epidural analgesia and perineal trauma.2–7 Results of those studies have conflicted. It has been suggested that by relaxing the muscles of the pelvic floor, epidural might allow more controlled delivery of the fetal head, reducing obstetric lacerations.2 However, epidural blockade could interfere with the second stage of labor, leading to increased obstetric intervention and perineal trauma. This study was carried out to determine if epidural analgesia for labor-pain relief is associated with differences in rates of severe perineal trauma (third- and fourth-degree obstetric lacerations) during vaginal deliveries in nulliparas, and evaluate any responsible factors.
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Materials and Methods |
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Obstetric practice at our institution is conducted in accordance with ACOG guidelines. There will always be some variation in practice according to provider; however, in general, routine episiotomies are not performed. At the time of the study, our unit allowed nulliparous women second stages of 2 hours without epidural and 3 hours with epidural, as ACOG recommends. Epidural was provided at all hours at women’s request. Nalbuphine (Nubain; Endo Pharmaceuticals, Chads Ford, PA) could be given at a dose of 10 mg intravenous (IV) or intramuscular (IM) at parturient request. Operative delivery was at the discretion of individual obstetricians.
During the study, the standard agents for epidural were bupivicaine and fentanyl. Blocks were induced by injecting 0.25% bupivacaine (12–16 mL) into the L2–3 or L3–4 interspace. After confirming adequate analgesia to at least the level of T10 bilaterally, a continuous infusion of 0.125% bupivicaine plus 2 µg/mL fentanyl was given at a rate of 8–10 mL/hour.
For this study, severe perineal lacerations were defined as third- or fourth-degree. Third-degree laceration was defined as involving the external anal sphincter but not extending through the rectal mucosa. Fourth-degree laceration was defined as extending through the rectal mucosa, exposing the lumen of the rectum. The rate of severe lacerations for women who had epidurals was compared with those who did not, overall and stratified according to episiotomies and assisted vaginal deliveries. Statistical significance was determined using 2. P < .05 was statistically significant. Logistic regression models were created to analyze significant associations while controlling for possible confounding variables.
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Results |
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The overall rates of third- and fourth-degree lacerations were 10.8% (n = 210) and 3.2% (n = 63), respectively. Epidurals were given to 1376 (70.9%) women among whom 16.1% had severe perineal lacerations compared with 9.7% of the 566 women who did not have epidurals (odds ratio [OR] 1.8, 95% confidence interval [CI] 1.3, 2.4; P < 001). The characteristics of women who had epidurals differed from those who did not (Table 1
). Women who had epidurals were more likely to have labor induced with oxytocin or have oxytocin to augment labor. Women who had epidurals were also more likely to have infants who weighed more than 4000 g, be older than 21 years, and have private medical insurance. Logistic regression (Table 2) to examine the association of epidurals with severe lacerations, while controlling for potential confounders of fetal size, use of oxytocin, maternal age, and lack of private insurance, found epidural to be a significant predictor of severe perineal injury (OR 1.4, 95% CI 1.0, 2.0).
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). Epidural was associated with significantly increased operative vaginal delivery and episiotomy. The proportion of operative vaginal deliveries was 21.1% (291 of 1376) in women who had epidurals and 5.7% (32 of 566) in those who did not. Of 1376 women who had epidurals, 741 had episiotomies (53.9%) compared with 183 (32.3%) of 566 who did not. Severe lacerations were more frequent with episiotomies (23.8% versus 5.5% [P = .001]) and operative vaginal deliveries (41.8% versus 8.7% [P = .001]).
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). For example, among women who had spontaneous deliveries and episiotomies, a similar percentage with and without epidurals had severe lacerations (14.1% versus 18.2%, P = 0.2). Of women who had operative vaginal deliveries and episiotomies, 46.6% of those who had epidurals (111 of 238) had severe perineal lacerations compared with 34.5% (10 of 29) of those who did not have epidurals (P = 0.2).
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). We found that when increased operative vaginal delivery and episiotomy associated with epidural were taken into account, epidural was no longer an independent predictor of severe perineal injury (OR 0.9; 95% CI 0.6, 1.3). Those results suggest that the increased use of operative intervention in women with epidurals was responsible for our association between epidural and severe perineal laceration. |
Discussion |
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Our results are consistent with a 1988 study by Legino et al that reported a higher rate of epidural use among women with third- and fourth-degree tears, in a population of nulliparous and multiparous women.4 In that study, 22% of women who had third- or fourth-degree lacerations (163 of 743) had epidurals, compared with epidural use in only 7% of women (273 of 3893) who did not have severe perineal traumas (P = .001). That study did not evaluate the reason for the increased rate of severe perineal trauma.
Walker et al, in a 1991 study of 8994 nulliparas and multiparas, concluded that epidurals were not associated with increased rate or severity of birth-canal trauma.2 However, those results were consistent with our findings because their conclusion was based on a multivariate model that controlled for use of forceps and episiotomy. They presented no crude data on the rate of perineal trauma according to epidural use. Combs et al, in a study of 2832 consecutive, operative vaginal deliveries, also reported no effect of epidural on third- or fourth-degree perineal lacerations,5 which is compatible with our results because we found that the increased severe perineal trauma associated with epidurals was associated with increased operative vaginal delivery and episiotomy that also accompanies epidural use.
To our knowledge, based on the literature search described above, our study is the only investigation to report an association of severe perineal trauma with epidural analgesia and explain the reason for this finding. In our study, nulliparas at term who had epidurals had markedly increased rates of third- and fourth-degree perineal tears. The association of operative vaginal delivery and epidural and the association of increased perineal trauma with operative vaginal delivery have been reported extensively.6–10 Given this, it is predictable that epidural analgesia is associated with a higher rate of third- and fourth-degree lacerations.
The history of pain relief in obstetric practice shows that different methods of analgesia can be used for medical, social, or cultural reasons. Of the methods of analgesia currently available for laboring women, epidural gives the best and most complete pain relief; however, its effectiveness is not without the cost of increasing the likelihood of third- or fourth-degree lacerations. Possible severe obstetric perineal trauma might concern many women. Besides discomfort immediately postpartum, there are possible long-term effects on the pelvic floor and anal-sphincter function.11,12 In a recent survey of obstetricians in London, 17% (33 of 206) of female obstetricians said they would chose cesarean without any clinical indication, 88% of them because they feared perineal damage.13
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Footnotes |
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Received October 29, 1998. Received in revised form January 6, 1999. Accepted January 28, 1999.
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References |
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2. Walker MP, Farine D, Rolbin SH, Ritchie JW. Epidural anesthesia, episiotomy, and obstetric laceration. Obstet Gynecol 1991;77:668–71.
3. Bickers WM. Epidural analgesia in obstetrics. J Reprod Med 1970;5:41–9.[Medline]
4. Legino LJ, Woods MP, Rayburn WF, McCoogan LS. Third- and fourth-degree tears. 50 year’s experience at a university hospital. J Reprod Med 1988;33:423–6.[Medline]
5. Combs CA, Robertson PA, Laros RK. Risk factors for third-degree and fourth-degree perineal lacerations in forceps and vacuum deliveries. Am J Obstet Gynecol 1990;163:100–4.[Medline]
6. Hoult IJ, MacLennan AH, Carrie LE. Lumbar epidural analgesia in labour: Relation to fetal malposition and instrumental delivery. BMJ 1977;1:14–6.
7. Studd JW, Crawford JS, Duignan NM, Rowbotham CJ, Hughes AO. The effect of lumbar epidural analgesia on the rate of cervical dilatation and the outcome of labour of spontaneous onset. Br J Obstet Gynaecol 1980;87:1015–21.[Medline]
8. Walton P, Reynolds F. Epidural analgesia and instrumental delivery. Anaesthesia 1984;39:218–23.[Medline]
9. Kaminski HM, Stafl A, Aiman J. The effect of epidural analgesia on the frequency of instrumental obstetric delivery. Obstet Gynecol 1987;69:770–3.[Medline]
10. Beynon CL. Midline episiotomy as a routine procedure. J Obstet Gynaecol Br Commw 1974;81:126–30.[Medline]
11. Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal-sphincter disruption during vaginal delivery. N Engl J Med 1993;329:1905–11.
12. Sultan AH, Kamm MA, Hudson CN, Bartram CI. Third degree obstetric anal sphincter tears: Risk factors and outcome of primary repair. BMJ 1994;308:887–91.
13. Al-Mufti R, McCarthy A, Fisk NM. Survey of obstetricians’ personal preference and discretionary practice. Eur J Obstet Gynecol Reprod Biol 1997;73:1–4.[Medline]
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