Comment: The quality of evidence is downgraded by inconsistency (unexplained variability in results) and upgraded by large magnitude of effect.
A Cochrane review [Abstract] 1 included 40 trials involving over 11 000 women. 34 trials compared epidural with opioids, 7 compared epidural with no analgesia, 1 trial compared epidural with acu-stimulation, 1 trial compared epidural with inhaled analgesia, and 1 trial compared epidural with continuous midwifery support and other analgesia. Compared with opioids, epidural analgesia resulted in less pain and less need for additional pain relief, higher satisfaction, and no difference between caesarean section rates or in neonatal outcomes (table T1). There was more need for assisted vaginal birth, but this effect was negated when trials before 2005 were excluded analysis. Compared with placebo/no treatment, pain scores were lower and satisfaction higher with epidural while there was no difference in instrumental delivery or caesarean section.
| Outcome | Relative effect(95% CI) | Risk with control - opioids | Risk with intervention - epidural (95% CI) | №of participants(studies) |
|---|---|---|---|---|
| Pain intensity measured using pain score in labour (lower scores = less pain) | - | SMD 2.64 lower(4.56 lower to 0.73 lower) | 1133(5) | |
| Satisfaction with pain relief (proportion rating excellent or very good) | Average RR 1.47(1.03 to 2.08) | 500 per 1000 | 735 per 1000(515 to 1000) | 1911(7) |
| Caesarean section | RR 1.07(0.96 to 1.18) | 114 per 1000 | 122 per 1000(110 to 135) | 10 350(33) |
| Admission to special care baby unit/neonatal intensive care unit | RR 1.03(0.95 to 1.12) | 204 per 1000 | 210 per 1000(194 to 228) | 4488(8) |
| Apgar score less than 7 at 5 minutes | RR 0.73(0.52 to 1.02) | 17 per 1000 | 12 per 1000(9 to 17) | 8752(22) |
Another Cochrane overview [Abstract] 2 included 15 Cochrane reviews (255 included trials) and 3 non-Cochrane reviews (55 included trials) of pain management in labour. Epidural and combined spinal epidural (CSE) effectively manage pain in labour, but may give rise to adverse effects. Epidural analgesia effectively relieve pain when compared with placebo or a different type of intervention (epidural versus opioids). Combined-spinal epidurals relieve pain more quickly than traditional or low dose epidurals.
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