title: Does early administration of epidural analgesia affect obstetric outcome in nulliparous women who are receiving intravenous oxytocin?
abstract: BACKGROUND
  Some studies suggest that epidural analgesia prolongs labor and increases the incidence of cesarean section, especially if it is administered before 5 cm cervical dilation. The purpose of the current study was to determine whether early administration of epidural analgesia affects obstetric outcome in nulliparous women who are receiving intravenous oxytocin.
  
  
  METHODS
  Informed consent was obtained from healthy nulliparous women with a singleton fetus in a vertex presentation, who requested epidural analgesia while receiving intravenous oxytocin at at least 36 weeks' gestation. Each patient was randomized to receive either early or late epidural analgesia. Randomization occurred only after the following conditions were met: (1) the patient requested pain relief at that moment, (2) a lumbar epidural catheter had been placed, and (3) the cervix was at least 3 but less than 5 cm dilated. Patients in the early group immediately received epidural bupivacaine analgesia. Patients in the late group received 10 mg nalbuphine intravenously. Late-group patients did not receive epidural analgesia until they achieved a cervical dilation of at least 5 cm or until at least 1 h had elapsed after a second dose of nalbuphine.
  
  
  RESULTS
  Early administration of epidural analgesia did not prolong the interval between randomization and the diagnosis of complete cervical dilation, and it did not increase the incidence of malposition of the vertex at delivery. Also, early administration of epidural analgesia did not result in an increased incidence of cesarean section or instrumental vaginal delivery. Thirteen (18%) of 74 women in the early group and 14 (19%) of 75 women in the late group underwent cesarean section (relative risk for the early group 0.94; 95% confidence interval 0.48-1.84). Patients in the early group had lower pain scores between 30 and 120 min after randomization, and were more likely to experience transient hypotension. Infants in the late group had lower umbilical arterial and venous blood pH and higher umbilical arterial and venous blood carbon dioxide tension measurements at delivery.
  
  
  CONCLUSIONS
  Early administration of epidural analgesia did not prolong labor or increase the incidence of operative delivery, when compared with intravenous nalbuphine followed by late administration of epidural analgesia, in nulliparous women who were receiving intravenous oxytocin.
authors.affiliation: Department of Anesthesia, University of Iowa College of Medicine, Iowa City.
authors.forename: D H
authors.initials: DH
authors.lastname: Chestnut
authors.forename: R D
authors.initials: RD
authors.lastname: Vincent
authors.forename: J M
authors.initials: JM
authors.lastname: McGrath
authors.forename: W W
authors.initials: WW
authors.lastname: Choi
authors.forename: J N
authors.initials: JN
authors.lastname: Bates
mesh_terms: D000328:Adult; D015360:Analgesia, Epidural / Q000009:adverse effects*; D016362:Analgesia, Obstetrical / Q000009:adverse effects*; D002045:Bupivacaine / Q000008:administration & dosage; D002585:Cesarean Section / Q000706:statistics & numerical data*; D004334:Drug Administration Schedule; D005260:Female; D006801:Humans; D007275:Injections, Intravenous; D007743:Labor, Obstetric / Q000187:drug effects; D010121:Oxytocin / Q000008:administration & dosage / Q000009:adverse effects*; D010147:Pain Measurement; D010298:Parity; D011247:Pregnancy
chemical_list: D010121:Oxytocin; D002045:Bupivacaine