title: Prophylactic intravenous preloading for regional analgesia in labour.
abstract: BACKGROUND
  Reduced uterine blood flow from maternal hypotension may contribute to fetal heart rate changes which are common following regional analgesia (epidural or spinal or combined spinal-epidural (CSE)) during labour. Intravenous fluid preloading may help to reduce maternal hypotension but using lower doses of local anaesthetic, and opioid only blocks, may reduce the need for preloading.
  
  
  OBJECTIVE
  To assess the effects of prophylactic intravenous fluid preloading before regional analgesia during labour on maternal and fetal well-being.
  
  
  METHODS
  We searched the Cochrane Pregnancy and Childbirth Group trials register (19 February 2004).
  
  
  METHODS
  Randomised and quasi-randomised trials comparing prophylactic intravenous preloading before regional analgesia during labour with a control group (dummy or no preloading).
  
  
  METHODS
  Two reviewers independently applied eligibility criteria, assessed trial quality and extracted data.
  
  
  RESULTS
  Six studies are included (473 participants). In one epidural trial using high-dose local anaesthetic, preloading with intravenous fluids was shown to counteract the hypotension which frequently follows traditional epidural analgesia (relative risk (RR) 0.07, 95% confidence interval (CI) 0.01 to 0.53; 102 women). This trial was also associated with a reduction in fetal heart rate abnormalities (RR 0.36, 95% CI 0.16 to 0.83; 102 women); no differences were detected in other perinatal and maternal outcomes for this trial and another high-dose epidural trial. In the two epidural low-dose anaesthetic trials, no significant difference in maternal hypotension was found (RR 0.73, 95% CI 0.36 to 1.48; 260 women), although they were underpowered to detect less than a very large effect. No significant differences were seen between groups in these trials for fetal heart rate abnormalities (RR 0.64, 95% CI 0.39 to 1.05; 233 women). In the two CSE trials, no differences were reported between preloading and no preloading groups. In the spinal/opioid trial, the RR for hypotension was 0.89, 95% CI 0.43 to 1.83 (40 women) and 0.70, 95% CI 0.36 to 1.37 for fetal heart rate abnormalities (32 women). In the opioid only study (30 women), there were no instances of hypotension or fetal heart rate abnormalities in either group.
  
  
  CONCLUSIONS
  Preloading prior to traditional high-dose local anaesthetic blocks may have some beneficial fetal and maternal effects in healthy women. Low-dose epidural and CSE analgesia techniques may reduce the need for preloading. The studies reviewed were too small to show whether preloading is beneficial for women having regional analgesia during labour using the lower-dose local anaesthetics or opioids. Further investigation of low-dose epidural or CSE (including opioid only) blocks, and the risks and benefits of intravenous preloading for women with pregnancy complications, is required.
authors.forename: G
authors.initials: G
authors.lastname: Hofmeyr
authors.forename: A
authors.initials: A
authors.lastname: Cyna
authors.forename: P
authors.initials: P
authors.lastname: Middleton
mesh_terms: D000767:Anesthesia, Epidural / Q000379:methods; D000773:Anesthesia, Obstetrical / Q000379:methods; D005260:Female; D005440:Fluid Therapy / Q000379:methods; D006340:Heart Rate, Fetal; D006801:Humans; D007022:Hypotension / Q000517:prevention & control*; D011247:Pregnancy; D011249:Pregnancy Complications, Cardiovascular / Q000517:prevention & control*; D016032:Randomized Controlled Trials as Topic