Epidural analgesia and breastfeeding: a randomised controlled trial of epidural techniques with and without fentanyl and a non-epidural comparison group.

We compared breastfeeding initiation and duration in 1054 nulliaparae randomised to bupivacaine Control epidural, Combined Spinal Epidural or Low Dose Infusion and 351 matched non-epidural comparisons. Women were interviewed after delivery and completed a postal questionnaire at 12 months. Regression analysis determined factors which independently predicted breastfeeding initiation. Breastfeeding duration was subjected to Kaplan-Meier analysis. A similar proportion of women in each epidural group initiated breastfeeding. Women with no epidural did not report a higher initiation rate relative to epidural groups and those who received pethidine reported a lower initiation rate than control epidural (p = 0.002). Older age groups (p < 0.001) and non-white ethnicity (p < 0.026) were predictive of breastfeeding. Epidural fentanyl dose, delivery mode and trial group were not predictive. Mean duration for breastfeeding was similar across epidural groups (Control 13.3, Combined Spinal Epidural 15.5, Low Dose Infusion 15.0 weeks). Our data do not support an effect of epidural fentanyl on breastfeeding initiation.

Urinary catheterization in labour with high-dose vs mobile epidural analgesia: a randomized controlled trial.

BACKGROUND: Dense perineal block from epidural analgesia increases the risk of urinary catheterization in labour. Mobile epidurals using low-dose local anaesthetic in combination with opioid preserve maternal mobility and may reduce the risk of bladder dysfunction. We conducted a three-arm randomized controlled trial to compare high-dose epidural pain relief with two mobile epidural techniques. METHODS: A total of 1054 primparous women were randomized to receive high-dose bupivacaine, epidural analgesia (Control), combined spinal epidural (CSE), or low-dose infusion (LDI). The requirement for urinary catheterization during labour and postpartum was recorded. Both end points were pre-specified secondary trial outcomes. Women were evaluated by postnatal interview, when their bladder function had returned to normal. RESULTS: Relative to Control, more women who received mobile epidural techniques maintained the ability to void urine spontaneously at any time (Control 11%, CSE 31% and LDI 32%) and throughout labour (Control 3.7%, CSE 13% and LDI 14%), for both mobile techniques P<0.01. There was no difference in the requirement for catheterization after delivery. Women in the CSE group reported a more rapid return of normal voiding sensation, relative to high-dose Control (P=0.02). CONCLUSIONS: Relative to conventional high-dose block, mobile epidural techniques encourage the retention of normal bladder function and reduce the risk of urinary catheterization in labour.

Ambulation in labour and delivery mode: a randomised controlled trial of high-dose vs mobile epidural analgesia.

Compared to high-dose epidurals where mobility is impossible, mobile epidurals have been shown to reduce instrumental vaginal delivery rates. The mechanism for this benefit may depend on women walking or adopting upright postures during labour. We investigated maternal motor power and ambulation of 1052 primparous women randomised to high-dose epidural (Control), Combined Spinal Epidural (CSE) or Low-Dose Infusion (LDI) as a pre-specified, secondary outcome of the Comparative Obstetric Mobile Epidural Trial. Modified Bromage power scores and the level of mobility a woman actually achieved were recorded each hour after epidural placement during first and second stage, until delivery. Relative to control, significantly more women maintained normal leg power throughout labour in both mobile groups and significantly more women with CSE maintained superior leg power for longer than with LDI. Observational analysis did not demonstrate an association between the level of ambulation a woman actually achieved after epidural placement and delivery mode.

Satisfaction, control and pain relief: short- and long-term assessments in a randomised controlled trial of low-dose and traditional epidurals and a non-epidural comparison group.

BACKGROUND: Childbirth is an important life event for which a positive experience is important to many women. METHODS: As secondary outcomes from the randomised controlled Comparative Obstetric Mobile Epidural Trial, various aspects of satisfaction were assessed in women who had one of three types of regional analgesia (two of which were low-dose techniques and a high-dose control using 0.25% epidural bupivacaine) and a comparison group who did not have epidural analgesia, shortly after delivery and 12 months later. RESULTS: The predominant finding was satisfaction with spontaneous vaginal delivery whatever the mode of analgesia. The overall immediate and long-term satisfaction was similar for all three neuraxial techniques. Satisfaction with the speed of pain relief and the amount of mobility were significantly greater for the combined spinal-epidural technique compared with the low-dose infusion (P<0.001). The degree of control felt by women who had combined spinal-epidural analgesia was greater than with the high-dose (P<0.05). Women in the non-epidural comparison group did not report a greater feeling of control. Among those who delivered spontaneously, more women in the combined spinal-epidural group (30%) felt in full control compared with the high-dose group (17%) (P<0.05). By comparison 22% in the low-dose infusion group and only 15% who had no epidural felt in full control. CONCLUSIONS: Whilst satisfaction with the experience of childbirth appears intimately related to the attainment of a spontaneous delivery, mobile epidurals enhance women's feeling of control in labour and are popular for future choice of regional analgesia.