June 2005 · Vol. 54, No. 6

• Clinical Question: Does early administration of neuraxial analgesia in labor increase the risk of cesarean delivery?

• Study Design: Randomized controlled trial (nonblinded)

• Allocation: Concealed

• Setting: Inpatient (ward only)

• Synopsis: Epidural analgesia, when given before a cervical dilatation of 4 cm, has been associated with higher cesarean delivery rate. Systemic narcotics are often used for women requesting analgesia in early labor.

  In this trial, 750 women with cervical dilatation of less than 4 cm were randomized at the first request for analgesia to a neuraxial analgesia group that received intrathecal fentanyl 25 mg or to a control group that received 1 mg intravenous hydromorphone plus 1 mg intramuscular hydromorphone. At the second request for analgesia, even with cervical dilatation still less than 4 cm, the neuraxial group received epidural analgesia with bupivacaine at half the usual strength plus fentanyl, while the control group received the same dosing of hydromorphone.

  The cesarean delivery rate was a similar 18% to 20% in the 2 groups. The mean time from first administration of analgesia to complete dilatation was 90 minutes shorter in the neuraxial group (295 minutes vs 385 minutes). Pain control after the first dose of analgesia was better in the neuraxial group (mean = 2 vs 6, on a 0–10 scale).

Bottom Line

Intrathecal fentanyl followed by epidural bupivacaine plus fentanyl, if needed for pain relief, in early labor is not associated with a higher cesarean delivery than systemic hydromorphone for early labor. The neuraxial approach also provides more effective analgesia and a shorter mean duration of first-stage labor. (LOE=1b)