Epidural Analgesia and Severe Perineal Laceration in a Community-based Obstetric Practice

Timothy G. Carroll, MD, Michael Engelken, MD, Michael C. Mosier, PhD, Niaman Nazir, MBBS, MPH

Disclosures

J Am Board Fam Med. 2003;16(1) 

In This Article

Abstract and Introduction

Background: This study assessed whether epidural analgesia was an independent risk factor for severe perineal laceration.
Methods: A retrospective cohort study analyzed 2,759 patients at St. Francis Regional Medical Center who had vertex, spontaneous or induced, singleton, live, vaginal deliveries of neonates of at least 36 weeks' gestation. Patients with diabetes or severe cardiac disease were excluded. Outcomes measured were third- or fourth-degree perineal lacerations.
Results: Overall rate of severe perineal laceration was 6.38% (n = 176). Epidural analgesia was given to 634 (22.98%) women. Among women who had epidural analgesia, 10.25% (65 of 634) had severe perineal lacerations compared with 5.22% (111 of 2,125) of the women who did not have epidural analgesia. After controlling for major variables in a logistic regression analysis, epidural analgesia remained a significant predictor of severe perineal injury (odds ratio [OR] = 1.528, 95% confidence interval [CI] = 1.092-2.137). When instrument use was included in the model, epidural analgesia was no longer a statistically significant, independent predictor of severe perineal injury. (OR = 1.287, 95% CI = 0.907-1.826). Instrument use was found to be a strong predictor of severe laceration (OR = 3.245, 95% CI = 2.162-4.869). A logistic regression model examining predictors of instrument use found that epidural analgesia does significantly predict instrument use (OR = 3.01, 95% CI = 2.225-4.075).
Conclusion: Epidural analgesia is associated with an increase in severe perineal trauma as a result of an associated threefold increased risk of instrument use. Instrument use in vaginal delivery more than triples the risk of severe perineal laceration.

Perineal trauma during vaginal delivery can have serious consequences. Long-term adverse effects of severe perineal laceration include chronic fecal incontinence, dyspareunia, perineal pain, and rectovaginal fistula. Severe laceration, such as a tear extending into the deep transverse perineal muscles and fibers of the anal sphincter (third degree) or rectal mucosa (fourth degree), is generally considered to occur with 5% of vaginal deliveries.[1] Some degree of perineal laceration, however, has been reported in up to 35% to 75% of all vaginal births.[2] A recent study found that 31% of female British obstetricians would choose cesarean delivery without any clinical indication because of concern about severe perineal damage.[3] Any factor that increases the real or perceived risk of perineal trauma is important.

Although increasingly popular, epidural analgesia has not been extensively studied as a risk factor for perineal damage. In some areas, epidural analgesia is administered in more than 70% of patients for vaginal delivery.[4] A determination of whether epidural analgesia is a risk factor for severe laceration has important consequences for decisions about delivery and potential long-term effects on maternal health.

A MEDLINE search of journal articles from 1970 to the present using terms related to this issue found only six studies exploring the association of epidural analgesia with severe perineal laceration. The results of these studies are conflicting. Three studies found epidural analgesia to be either protective or not associated to perineal laceration.[5,6,7] A potential explanation for this result is that epidural analgesia causes the perineal muscles to relax, allowing for a more controlled delivery of the fetal head. Conversely, the three other studies reported that epidural analgesia is associated with higher rates of laceration.[4,8,9] Explanations for this finding have included increased use of operative delivery methods, lengthened second stage of labor, and increased amounts of fetal malposition (occiput posterior and transverse) during delivery when epidural analgesia is used.[8,10,11] With the conflicting results of these studies, it is highly relevant to explore whether epidural analgesia carries an increased risk of perineal tear using data relevant to a community-based practice.

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