Epidural Analgesia and the Risk of Third and Fourth Degree Obstetric Laceration in Nullipara Women

Background: Epidurals are commonly used to relieve labor pain; they are not without risk. Epidurals lengthen the length of the second stage of labor, cause maternal hypertension, itching, shivering, fever, urinary retention, vomiting, and dural puncture. Methods: An exhaustive search of available medical literature was conducted using Medline-OVID, CINAHL, EBMR and Web of Science using the keywords: lacerations, epidural analgesia. Studies were included if they had minimum sample size of 1000 and were conducted on nullipara women. The Quality of relevant articles was assessed using GRADE. Results: Three studies met inclusion criteria and were used in this systematic review. A retrospective cohort study, conducted in 1999, evaluating 1942 participants showed that epidural analgesia prolongs the second stage of labor, and it is indirectly associated with an increased rate of severe perineal trauma. A 2002 retrospective cohort study with 1059 women showed a significant increase in perineal trauma due to an associated threefold increase risk of instrument use in delivery. A retrospective cohort study conducted in 1991 with 3745 deliveries showed that epidural analgesia was associated with more episiotomies; however, the authors concluded it was not directly associated with an increase incident of birth canal trauma. Conclusion: Epidural analgesia is a risk factor in causing severe perineal trauma in the nullipara patient due to its more frequent use of episiotomy and instrumental delivery