Use of epidural analgesia and emergency delivery for fetal compromise: post-hoc analysis of the RAVEL study, multicenter randomized controlled trial.

OBJECTIVES: To report on the association of epidural analgesia with emergency delivery for fetal compromise compared to remifentanil patient-controlled analgesia and describe the association with birthweight for gestational age.

METHODS: A post hoc per-protocol analysis of the RAVEL study, a multicentre randomised controlled equivalence trial. Singleton, non-anomalous pregnancies between 36+0 and 42+6 weeks of gestation were at pain relief request randomised to either epidural analgesia or remifentanil patient-controlled analgesia. The primary outcome was emergency delivery for fetal compromise. Secondary outcomes included delivery and neonatal outcomes. Analyses were according to birth weight quintile groups, corrected for relevant confounding variables.

RESULTS: 619 pregnant women were included, of whom 336 were allocated to remifentanil patient-controlled analgesia (RPCA) and 283 to EDA. Of all women receiving EDA, 14.8% had an emergency delivery for fetal compromise compared to 8.3% in women with RPCA. After adjusting for parity, women receiving EDA had a higher odds ratio for fetal compromise compared to RPCA (OR = 1.69, 95% CI [1.01, 2.83]. A statistically significant linear-by-linear association was observed between fetal compromise and birthweight quintile (p=0.003). The incidence of emergency delivery for fetal compromise was highest in women receiving EDA and within the lowest birthweight quintile.

CONCLUSIONS: In the per-protocol analysis, intrapartum EDA is associated with higher emergency delivery rates for fetal compromise compared to treatment with RPCA. Infant weight percentile is a strong predictor of fetal compromise, independent of treatment. This article is protected by copyright. All rights reserved.