Cochrane Briefs

Am Fam Physician. 2005 Apr 1;71(7):1303.

Effects of Discontinuing Epidurals in Late Labor

Clinical Question

Does discontinuing epidural analgesia in the second stage of labor reduce rates of instrumented delivery or change patient satisfaction with labor?

Evidence-Based Answer

Based on three good studies of 462 patients, discontinuing epidural analgesia in the second stage of labor does not significantly change rates of instrumented delivery or other delivery outcomes, but it increases rates of inadequate pain relief.

Practice Pointers

The American College of Obstetricians and Gynecologists1 supports the use of epidural analgesia during labor. The policy states that epidurals should not be denied because of the patient’s insurance and that nurses should not be restricted from managing regional anesthesia.1 Because epidural analgesia provides the highest level of pain relief, the physician and patient should decide when it should be used. However, there are concerns that epidural analgesia increases rates of instrumented deliveries. To reduce this risk, physicians sometimes discontinue epidural analgesia during the second stage of labor. Torvaldsen and colleagues reviewed the literature to determine if this practice improves outcomes.

The authors found five studies, three of which were good quality. They did not find a statistically significant difference in rates of instrumented delivery or cesarean delivery, duration of the second stage of labor, low Apgar scores, or fetal malposition at delivery. The only statistically significant difference was an increased rate of inadequate pain relief during the second stage of labor.

Some women may be willing to accept discomfort in the second stage of labor even if the risk of poor outcomes is small. A larger study is needed to determine if there is a difference in outcomes. There is inadequate data to support the practice of discontinuing epidural analgesia in the second stage of labor.

REFERENCES

1. American College of Obstetricians and Gynecologists. ACOG committee opinion no. 295: pain relief during labor. Obstet Gynecol. 2004;104:213.

Comparison of Short-Term Treatments for GERD

Clinical Question

Which medications improve outcomes in patients with symptoms of gastroesophageal reflux disease (GERD) who are treated empirically and in those with symptoms but a normal endoscopy?

Evidence-Based Answer

For empiric treatment of GERD or endoscopy-negative reflux disease, a short trial of a proton pump inhibitor increases the chance of remission. Histamine H2-receptor antagonists are less expensive and work well in many patients, particularly those with less severe symptoms or endoscopy-negative reflux disease.

Practice Pointers

GERD is extremely common, and most patients are treated empirically. Endoscopy can diagnose esophagitis, ulcers, bleeding, strictures, Barrett’s esophagus, and carcinoma. Urgent upper endoscopy should be performed in patients with melena, hematemesis, persistent vomiting, anemia, acute onset of total dysphagia, or involuntary weight loss of more than 5 percent of total body weight. Patients older than 45 to 50 years should receive nonurgent endoscopy. Younger patients should be considered for endoscopy if they are at risk for gastric cancer.12 Pinxeren and colleagues reviewed the literature to determine which treatments benefit patients with symptoms of GERD who are treated empirically, and which options are effective in patients with GERD symptoms but a normal endoscopy.

The authors found 27 trials with 8,402 participants ranging from 18 to 79 years of age (mean age, 48 years); 45 percent of participants were men. Most of the trials were of adequate quality. Patients who were treated empirically had a remission in heartburn when they received proton pump inhibitors (relative risk [RR], 0.37; 95 percent confidence interval [CI], 0.32 to 0.44) and histamine H2-receptor antagonists (RR, 0.77; 95 percent CI, 0.60 to 0.99). In direct comparisons, proton pump inhibitors were significantly more effective than histamine H2-receptor antagonists and prokinetics in achieving remission. No significant differences were noted between proton pump inhibitors and histamine H2-receptor antagonists in patients with endoscopy-negative reflux disease.

The results of this study did not identify differences between proton pump inhibitors (such studies are lacking). Because many patients do well with a histamine H2-receptor antagonist at much lower cost, these drugs still should be considered viable treatment options for many patients. The cost difference between the newest proton pump inhibitor (rabeprazole; $4.50 per day) and generic omeprazole (less than $1 per day) or ranitidine (less than $0.50 per day) is substantial.

REFERENCES

1. Institute for Clinical Systems Improvement. Dyspepsia and GERD. Bloomington, Minn.: Institute for Clinical Systems Improvement, 2004.

2. Evaluation of dyspepsia. American Gastroenterological Association medical position statement: evaluation of dyspepsia. Gastroenterology. 1998;114:579–81.


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