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An Impact Study of Availability of Epidural Labor Analgesia on the Rate of Cesarean Delivery − A Report from the Chinese No Pain Labor N’ Delivery Experience
Abstract Number: BP-5
Abstract Type: Original Research
Introduction: Although randomized clinical trials suggest that neuraxial labor analgesia (NA) does not increase the risk of cesarean delivery (CD), its impact on operative vaginal delivery (OVD) and other safety outcomes are still controversial. In 2008,the No Pain Labor N’ Delivery (NPLnD) program was launched in China to teach safe and effective NA. The current NA rate is <1% and the CD rate is > 50%. The aim of this study was to evaluate the impact of the introduction of NA on mode of delivery in a single Chinese hospital.
Methods: Data were collected retrospectively from preexisting databases from the Shijiazhuang Obstetrics and Gynecology Hospital(08/2009-08/2011). Variables included the total number of deliveries and mode of delivery, indications for CD, overall clinic visits and hospital admissions, 5-min Apgar score ≤ 3, infant death ≤ 7 days, postpartum hemorrhage(PPH), and maternal death. The obstetric anesthesia service was started on 01/11/10(M-F,0800-1730), became 24/7 on 07/17/10, and become part of a fee-for-service incentive stimulation package on 11/12/10. A one-day education event was provided to pregnant women, obstetric health care providers and hospital administrators by the primary author from Northwestern University(NU) on 08/28/10. The modified NPLnD Protocol derived from the current practice in NU was used (epidural 0.075-0.1% ropivacaine + sufentanil 0.1-0.2μg/mL, infused after bolus doses). Data were compared among 3 periods: 08-12/09(baseline; NA rate 0%), 01-08/10(phase-in; NA rate from 4.6% to 40.3%), and 09/10–08/11(final phase; NA rate > 45%) using X2.
Results: There were 19,938 deliveries in the 25-month study period. The NA rate increased from 0% to 59% and monthly delivery rate increased from 757 to 1056. The mean (±SD) of the clinic visits/delivery (47.6±6.6) and the hospital admissions/delivery(2.2±0.3) did not change. The mode of delivery data are shown in Figure 1. Figure 2 illustrates the incidences of maternal and perinatal death, PPH, and Apgar ≤ 3. There was a significant difference in the CD rate between the baseline and phase-in epochs (-2.3%, 95%CI -0.3%,-4.3%, p=0.03) and the phase-in and final epochs(-4.5%, 95%CI -0.3%,-6.0%, p=0.0002). The OVD rate did not change. The Apgar ≤ 3 rate decreased from 1.4% to 1.1%, to 0.9% (p<0.001).
Discussion: The important finding is that the introduction of NA was associated with a significant decrease in the CD rate and the number of neonates with Apgar ≤ 3. No safety indicators worsened. We suggest that the introduction of NA to Chinese women may be one method to improve labor and delivery outcomes.