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Obstetric factors associated with intrapartum fetal head malrotation under in different methods of neuraxial analgesia
Abstract Number: S 24
Abstract Type: Original Research
Introduction: Fetal head malrotation is one of the factors for dystocia and reported to increase the adverse obstetric and neonatal outcomes. Especially it is of great concern during intrapartum period for obstetric management. Epidural analgesia and/or its motor blockade have been proposed as a cause of increased incidence of intrapartum malrotation. We previously demonstrated that method of neuraxial analgesia or degree of motor block of the lower extremities did not affect fetal head malrotation in labor1. In this study, we tested whether obstetric factors correlated intrapartum fetal head malrotation under different degree of motor block in labor analgesia.
Methods: Singleton, low risk term deliveries with vertex position were enrolled. Prospectively, participants were randomly allocated to either 3 analgesic groups stratified by parity: intermittent epidural injection with bupivacaine, continuous epidural infusion with ropivacaine plus fentanyl, or combined spinal-epidural analgesia. Fetal head malrotation was defined occiput posterior position at any time of labor and delivery, and occiput transverse position before pushing and at delivery. Fetal head rotation was recorded at start of analgesia, before pushing, and at delivery. Modified Bromage score were recorded 30 min after neuraxial analgesia and at delivery. Multivariable analysis was performed for obstetric factors and maternal and neonatal outcomes.
Results: Three hundred and five women completed the study. Incidence of fetal head malrotation was as follows; 9.6%, 16.7%, 7.8% at start of analgesia, before pushing, and at delivery in primipara, and 14.1%, 18.8%, 6.0% in multipara, respectively. Fetal head malrotation at start of analgesia was strongly associated with fetal head malrotation before pushing (primipara: P < 0.001, multipara: P = 0.002). Early artificial rupture of membrane < 5 cm cervical dilatation was also associated with malrotation before pushing in primipara (P = 0.02), but not in multipara (P = 0.56). In cases with malrotation before pushing, instrumental delivery increased significantly in multipara (primipara: P = 0.07, multipara: P = 0.002), while cesarean delivery increased significantly in primipara (primipara: P = 0.003, multipara: P = 0.19). Labor induction, degree of motor block, method of neuraxial analgesia, Apgar score, NICU admission, perineal injury, or bleeding had no association with intrapartum fetal head malrotation.
Conclusions: The incidence of intrapartum fetal head malrotation was associated with existing malrotation at start of analgesia in this study. In primipara, artificial rupture of membrane before 5cm cervical dilation was also associated intrapartum fetal head malrotation.
Reference: 1) Okada H, et al. The effect of neuraxial analgesia on fetal head malrotation: Comparison of intermittent epidural injection, continuous epidural infusion, and combined spinal-epidural analgesia. 2011 SOAP annual meeting abstract #18.