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Effect of Timing of Combined Spinal Epidural Placement and Amniotomy on the Incidence of Fetal Bradycardia
Abstract Number: F5A-5
Abstract Type: Original Research
The provision of combined spinal-epidurals (CSE) for labor analgesia is associated with an increased risk of fetal bradycardia, particularly if intrathecal opioids are included in the intrathecal dose (1). Similarly, early amniotomy may predispose to fetal bradycardia (2). In clinical practice, CSE placement and amniotomy often occur in close temporal conjunction, but it is unclear whether the time interval between these events influences the incidence of fetal bradycardia. This retrospective cohort study evaluated the relationship between the timing of amniotomy and CSE placement, and the incidence of fetal bradycardia. We hypothesized that CSE placement within 90 minutes of amniotomy (either before or after) would increase the risk of fetal bradycardia.
Data were collected from all laboring (spontaneous or induction of labor) patients from 1/1/16 to 12/31/16 who underwent amniotomy after hospital admission and received a CSE. Three groups were identified: women who underwent CSE followed by amniotomy within 90 minutes (group A), women who underwent amniotomy followed by CSE within 90 minutes (group B), and patients for whom CSE and amniotomy were separated by more than 90 minutes (group C). The primary outcome was the incidence of fetal bradycardia requiring further assessment by obstetrical and anesthesiology providers. Secondary outcomes were the incidences of caesarean delivery and hypotension requiring vasopressor administration.
4847 patient charts were reviewed, with 1921 patients in Group A, 898 patients in group B, and 2028 patients in group C. The incidence of fetal bradycardia was not different between groups A (11.6%) and C (13.7%) (P=0.11) or between groups B (13.0%) and C (P=0.65). Both groups A (10%, P<0.001) and B (10%, P<0.001) had lower rates of cesarean delivery than group C (15%). There were no differences among groups in rates of hypotension.(Table 1)
Close timing of CSE and amniotomy did not affect the incidence of fetal bradycardia or maternal hypotension, but was associated with a decreased risk for cesarean delivery. The clinical significance of this is unclear, but may be reflective of patients with favorable labor curves. Alternatively, this may reflect maternal characteristics or other aspects of labor such as differential use and timing of oxytocin between groups.
1. Mardirosoff. Br J Obstet Gyaecol 2002;1909:274-281
2. Goffinet. Br J Obstet Gynaecol. 1997,104(5):548-53