CESAREAN DELIVERY - A RANDOMIZED TRIAL OF EPIDURAL VERSUS PATIENT-CONTROLLED MEPERIDINE ANALGESIA DURING LABOR

Background: Reports indicate that the administration of epidural analg esia for pain relief during labor interferes with labor and increases cesarean deliveries. However, only a few controlled trials have assess ed the effect of epidural analgesia on the incidence of cesarean deliv ery. The authors' primary purpose in this randomized study was to eval uate the effects of epidural analgesia on the rate of cesarean deliver ies by providing a suitable alternative: patient-controlled intravenou s analgesia. Methods: Seven hundred fifteen women of mixed parity in s pontaneous labor at full term were randomly assigned to receive either epidural analgesia or patient-controlled intravenous meperidine analg esia. Epidural analgesia was maintained with a continuous epidural inf usion of 0.125% bupivacaine with 2 mu g/ml fentanyl. Patient-controlle d analgesia was maintained with 10-15 mg meperidine given every 10 min as needed using a patient-controlled pump. Procedures recorded in a m anual that prescribed the intrapartum management were followed for eac h woman randomized in the study. Results: A total of 358 women were ra ndomized to receive epidural analgesia, and 243 (68%) of these women c omplied with the epidural analgesia protocol. Similarly, 357 women wer e randomized to receive patient-controlled intravenous meperidine anal gesia, and 253 (73%) of these women complied with the patient-controll ed intravenous analgesia protocol. Only five women who were randomized and received patient-controlled intravenous meperidine analgesia acco rding to the protocol crossed over to epidural analgesia due to inadeq uate pain relief. There was no difference in the rate of cesarean deli veries between the two analgesia groups using intention-to-treat analy sis based on the original randomization (epidural analgesia, 4% [95% C I: 1.9-6.2%] compared with patient-controlled intravenous analgesia, 5 % [95% CI: 2.6-7.2%]). Similar results were observed for the analysis of the protocol-compliant groups (epidural analgesia, 5% [95% CI: 2.6- 8.5%] compared with patient-controlled intravenous analgesia, 6% [95% CI: 3-8.9%]). Women who received epidural analgesia reported lower pai n scores during labor and delivery compared with women who received pa tient-controlled intravenous analgesia. Conclusions: Epidural analgesi a was not associated with increased numbers of cesarean delivery when compared with a suitable alternative method of analgesia.