title: Epidural analgesia and third- or fourth-degree lacerations in nulliparas.
abstract: OBJECTIVE
  To determine if epidural analgesia is associated with differences in rates of severe perineal trauma during vaginal deliveries.
  
  
  METHODS
  We studied 1942 consecutive, low-risk, term, vaginal deliveries in nulliparas, including spontaneous and induced labors, at a single institution from December 1994 to August 1995. The rate of third- and fourth-degree lacerations was compared for women who had and did not have epidural analgesia for labor-pain relief. Statistical significance was determined using chi2. Logistic regression analyses were used to evaluate associations while controlling for possible confounding variables.
  
  
  RESULTS
  Overall rates of third- and fourth-degree lacerations were 10.8% (n = 210) and 3.4% (n = 63), respectively. Epidural analgesia was given to 1376 (70.9%) women. Among women who had epidurals, 16.1% (221 of 1376) had severe perineal lacerations compared with 9.7% (n = 55) of the 566 women who did not have epidurals (P < .001; odds ratio [OR] 1.8, 95% confidence interval [CI] 1.3, 2.4). When controlling for birth weight, use of oxytocin, and maternal age in logistic regression analysis, epidural remained a significant predictor of severe perineal injury (OR 1.4, 95% CI 1.0, 2.0). Epidural use is consistently associated with increased operative vaginal deliveries and consequent episiotomies, so we constructed a logistic regression model to evaluate whether the higher rates of those procedures were responsible for the effect of epidurals on severe perineal traumas. With operative vaginal delivery and episiotomy in the model, epidural was no longer an independent predictor of perineal injury (OR 0.9, 95% CI 0.6, 1.3).
  
  
  CONCLUSIONS
  Epidural analgesia is associated with an increase in the rate of severe perineal trauma because of the more frequent use of operative vaginal delivery and episiotomy.
authors.affiliation: Department of Maternal Fetal Medicine, Brigham & Women's Hospital, Boston, Massachusetts 02115, USA. jnrobinson@bics.bwh.harvard.edu
authors.forename: J N
authors.initials: JN
authors.lastname: Robinson
authors.forename: E R
authors.initials: ER
authors.lastname: Norwitz
authors.forename: A P
authors.initials: AP
authors.lastname: Cohen
authors.forename: T F
authors.initials: TF
authors.lastname: McElrath
authors.forename: E S
authors.initials: ES
authors.lastname: Lieberman
mesh_terms: D000328:Adult; D015360:Analgesia, Epidural; D004841:Episiotomy / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D010298:Parity; D010502:Perineum / Q000293:injuries*; D011247:Pregnancy; D014947:Wounds and Injuries / Q000453:epidemiology