Management of Incoordinate Uterine Action under Continuous Epidural Analgesia
Authors: D. D. Moir, J. Willocks
Journal: BMJ (1967)

British anaesthetists and obstetricians have made little use of epidural analgesia in obstetrics. From time to time small series have been reported by British workers who have used caudal or lumbar epidural analgesia in incoordinate uterine action (Galley, 1949 ; Johnson, 1952, 1954, 1957 ; Arthur and Johnson, 1952 ; Ball and Chambers, 1956 ; Tunstall, 1960) and in pre-eclampsia tnd eclampsia (Bryce-Smith and Williams, 1955 ; Scott, 1955). In contrast, epidural techniques are extensively used for obstetric analgesia in many North American centres (Bush, 1959 ; Hingson et al., 1961 ; Hellmann, 1965 ; Moore, 1966) following on the pioneer work of Hingson and Edwards (1943). The reasons for this difference in practice are several. Firstly; British obstetric opinion is generally in favour of encouraging spontaneous delivery where this can safely be achieved, and most spontaneous deliveries are conducted by midwives in hospital and at home. Epidural analgesia, because it produces perineal anaesthesia and so abolishes the reflex expulsive efforts of the second stage of labour, is usually asso ciated with a high forceps delivery rate. Secondly, epidural analgesia may be required at any time of the day or night, and its safe conduct necessitates the presence of an anaesthetist experienced in the technique for as long as the block is maintained. This demands a 24-hour obstetric anaesthetic service by experienced anaesthetists who are not committed to other duties. This service exists in few hospitals in Great Britain today, though in our experience the benefits are substantial and not confined to the administration of epidural analgesia. Finally, there exist anaesthetists and obstetricians who believe, despite impressive evidence to the contrary, that epidural anal gesia is a difficult and dangerous technique. With experience the success rate can approach 100%, particularly in younger women without spinal deformities or the ossification of the supraspinous ligament which may develop in the elderly. The potential dangers of epidural analgesia should not be minimized, but with awareness of these dangers and constant attention to details in technique and management by a team of anaesthetists, obstetricians, and midwives the method is acceptably safe. The vast experience of others confirms this safety. Norris et al. (1960) reported over 9,000 epidural blocks in labour, and Hellmann (1965) reported over 26,000 cases. In neither series was there any foetal or maternal mortality attributable to epidural analgesia, and the incidence of complications was very low. Continuous observation is essential for safety, and an extra burden is thereby placed on nursing staff, who, in our experience, accept this willingly when convinced of the value of the procedure. It is not our intention, however, to advocate the routine adoption of epidural analgesia for relief of pain in normal labour. In the Queen Mother's Hospital, Glasgow, continuous lumbar epidural analgesia is used in just over 4% of all labours and, in addition,  single-shot  epidural analgesia is used for 9% of mid-cavity forceps deliveries. During the last two and a half years 246 continuous epidural blocks have been given to patients in labour. In the 100 cases reported here the indication was incoordinate uterine action. The present review was under taken to assess the contribution made by epidural analgesia to the management of these cases.