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Association between neuraxial analgesia and perineal trauma after vaginal delivery of patients with intra-uterine fetal demise (IUFD)
Abstract Number: F-22
Abstract Type: Original Research
Introduction: Neuraxial analgesia has been cited as a risk factor for perineal trauma during vaginal delivery, although studies have shown conflicting results. Furthermore, the association between neuraxial analgesia and perineal trauma in patients with intrauterine fetal demise (IUFD) has not been carefully studied. The purpose of this study was to evaluate the incidence of perineal trauma with and without neuraxial analgesia and to model the relative risk of perineal laceration among risk factors in this patient population.
Methods: Patients with a diagnosis of IUFD from 2007 through 2016 were included in this retrospective study. The primary outcome was the incidence of perineal trauma in patients with IUFD in relation to the analgesic modality during labor and delivery. Secondary outcomes included the degree of laceration and the association of bupivacaine concentration with the incidence of laceration.
Results: A total of 442 patients met the definition of IUFD. There were 329 patients (78%) that received neuraxial analgesia. The incidence of perineal laceration was 20.2% (n=79); of those, 71 parturients received neuraxial analgesia compared to 8 patients in non-neuraxial group (23.1% vs. 9.5%, P<0.001). Among patients with perineal trauma in the neuraxial group, 38 patients (53.5%) received an infusion of bupivacaine 0.11% compared to 32 patients (45.1%) with bupivacaine 0.0625% (P=0.36). Multivariate logistic regression identified increased birth weight (OR=3.6, 95% CI [2.0, 6.6], P<0.001), lower BMI (OR=0.93, 95% CI [0.87, 0.99], P=0.014) and lower parity (OR=0.44, 95% CI [0.28, 0.69], P<0.001) as independent predictors of perineal laceration. The predictive accuracy (c-statistic) of the model was 0.91 (95% CI [0.87, 0.95]).
Conclusion: Neuraxial analgesia had a strong association with perineal injury. However, its causality is unclear due to selection bias from our clinical practice. Increased instrumental vaginal delivery related to neuraxial analgesia could play a role even though this technique is infrequently used in IUFD delivery at our institution. High birth weight was found to increase the incidence of perineal trauma significantly, while high BMI and increased parity appear to be protective.
1. L.M. Christianson et al. J Obst Gynecol 2003 July; 255-260
2. M. Basu et al. Int Urogynecol J 2014; 25:61-64