Epidural blockade in obstetrics--how safe?

Complications of obstetric epidural analgesia and anaesthesia: a prospective analysis of 10 995 cases

Although epidural anaesthesia and analgesia are widely used in obstetrics, there are no large contemporary prospective series detailing associated complications. Prospective data was collected on all obstetric epidural blocks performed for labour and delivery in a single institution between July 1989 and August 1994. A data entry sheet was compiled and entered onto a computer database. Confidence intervals for proportions were calculated using standard methods. Information from 10 995 epidural blocks was analysed. Epidural analgesia in labour was the primary indication in 7648, and anaesthesia for caesarean section in 3311. Minor complications included failed or abandoned insertion (incidence 0.5%), reinsertion of the epidural catheter (5%), and inadequate anaesthesia (1.7%) or analgesia (0.9%). Three percent were associated with venous puncture and 0.6% with accidental dural puncture. Maternal mortality was zero. Unexpectedly high blocks occurred on eight occasions (0.07%), two requiring intubation and ventilation. Three women (0.06%) experienced mild respiratory depression after postoperative epidural opioid. There was no major local anaesthetic toxicity or neurological deficit. The incidence of potentially life-threatening morbidity was thus 0.02% although in both cases outcome was good. The only persisting complication was neurological, an apparent epidural catheter-induced traumatic mononeuropathy.

Epidural analgesia in labor: an evaluation of risks and benefits

BACKGROUND

Intrapartum epidural analgesia has become increasingly popular because it is the most effective method of providing pain relief during labor. Much attention is given to its safety and efficacy, and many health care providers and consumers are unaware of its potential drawbacks. This article reviews the literature about the effects of epidural analgesia on the mother and infant.

METHODS

We performed a computer-assisted MEDLINE search for articles and a review of bibliographies from articles on epidural analgesia. When reported data were incomplete, authors were contacted for more detailed information.

RESULTS

The most common procedure-related complications, hypotension, inadvertent dural puncture, and headache, are easily treated and usually self-limited. Permanent morbidity and mortality are rare. Retrospective studies and randomized controlled trials both demonstrate that epidural analgesia is associated with increases in duration of labor, instrument vaginal delivery, and cesarean birth. To date only three trials randomized patients to narcotic versus epidural groups, and all showed a twofold to threefold increase in cesarean section for dystocia. Limiting epidural use in nulliparous labor and delaying its placement until after 5 cm of cervical dilation may reduce the risk of operative intervention for dystocia. Epidural analgesia may also increase intervention for fetal distress. Several studies show its association with maternal fever in labor. Its association with chronic back pain, neonatal behavioral changes, and maternal-infant bonding are more tenuous and require further study.

CONCLUSIONS

Epidural analgesia is a safe and effective method of relieving pain in labor, but is associated with longer labor, more operative intervention, and increases in cost. It must remain an option; however, caregivers and consumers should be aware of associated risks. Women should be counseled about these risks and other pain-relieving options before the duress of labor.