REVIEW QUESTION

What are the safest and most effective analgesic agents or methods to use for a forceps delivery?

TYPE OF REVIEW

This is a Cochrane systematic review of four randomized controlled trials (RCTs) comparing the use of different analgesic agents and methods in a forceps delivery.

RELEVANCE FOR NURSING

The use of forceps in childbirth may be indicated when a fetus fails to progress to delivery or when the birth needs to be expedited in the second stage of labor. Effective analgesia is required to ensure that the woman is comfortable so that the obstetrician can safely perform the procedure. It is unclear which agent or method is the most effective and safe in providing pain relief during a forceps delivery. Clinical practice guidelines recommend that "appropriate analgesia" should be administered, although they do not provide further guidance as to the agent or method to use.

CHARACTERISTICS OF THE EVIDENCE

Four RCTs conducted prior to 1980 (involving 388 pregnant women in the second stage of labor undergoing forceps delivery for any indication) were included in the review. Interventions were an analgesic agent or a technique used for forceps delivery compared with an alternative agent or method or with placebo/no treatment. The primary outcomes were pain relief during forceps birth, serious maternal adverse effects or complications associated with the intervention, and neonatal mortality or serious morbidity (however the four trials only reported on the first outcome).

Three trials compared diazepam with alternative agents for the provision of general anesthesia during forceps birth. No significant difference in pain relief was found when diazepam was compared with ketamine in one small trial. In another trial comparing diazepam with vinydan-ether, the women receiving diazepam were significantly more likely to judge their pain relief as effective. The third trial, which compared diazepam with "other anaesthesia" (including general, local, or other), reported data on "amnesic effect" and "women's behaviour" only for the group of women receiving diazepam. Any benefits of diazepam should be interpreted with caution, however, given its potential dangers in obstetric patients, which were unknown at the time these studies were published.

In the fourth trial, which compared the use of spinal analgesia with pudendal block, women receiving spinal analgesia were significantly more likely to regard the pain relief as adequate and less likely to report severe pain during delivery.

BEST PRACTICE RECOMMENDATIONS

There is insufficient evidence to support one technique or agent as most effective and safe in providing analgesia during a forceps birth.

While this review suggests the possible benefits of diazepam versus vinydan-ether and of spinal analgesia versus pudendal block, it is important to note that the results are based on four small, low-quality randomized trials, each conducted prior to 1980, and which predominately assessed agents and techniques infrequently or even no longer used in clinical practice.

RESEARCH RECOMMENDATIONS

Well-designed, adequately powered RCTs are needed to determine the most effective and safe agents or methods for providing analgesia during a forceps birth.

Such trials should consider the agents or methods used in current practice (such as epidural, caudal analgesia, and local anaesthesia to the perineum). In assessing effectiveness and safety, trials should consider relevant maternal and neonatal/infant outcomes.

SOURCE DOCUMENT