• type of vaginal delivery [ Designated as safety issue: Yes ]
• duration of labor [ Designated as safety issue: Yes ]
• indication for cesarean delivery [ Designated as safety issue: Yes ]
• analgesia efficacy
• analgesia side effects [ Designated as safety issue: Yes ]
• neonatal outcome [ Designated as safety issue: Yes ]

• type of vaginal delivery
• duration of labor
• indication for cesarean delivery
• analgesia efficacy
• analgesia side effects
• neonatal outcome

The purpose of this study in nulliparous women undergoing induction of labor is to determine whether initiation of neuraxial analgesia compared to systemic opioid analgesia early in labor (< 4 cm cervical dilation)affects the cesarean delivery rate.

Women in early labor frequently request pain medication. Obstetricians may prescribe narcotics (administered as an intravenous (IV) or intramuscular (IM) shot). However, IV or IM narcotics provide incomplete pain relief and have maternal and fetal/neonatal side effects, e.g., maternal drowsiness, respiratory depression, nausea, and vomiting, and neonatal respiration depression. Other obstetricians allow their patients to request early neuraxial (spinal or epidural) analgesia. The results of several studies comparing patients who received epidural vs. IV/IM narcotic labor analgesia (not specifically early labor) suggest that initiation of early neuraxial analgesia may be associated with higher Cesarean delivery rates. It has been hypothesized that epidural/spinal local anesthetics may induce pelvic musculature relaxation leading to failure of fetal descent and rotation. However, early pain may be a marker for other factors that increase the risk of Cesarean delivery, e.g., large or malpositioned baby, or dysfunctional labor. Whether or not early neuraxial analgesia (particularly if narcotic based, which would not cause pelvic muscle paralysis) compared to IV/IM narcotics, adversely affects the outcome of labor has not been studied in a randomized, prospective fashion. The purpose of this study is to compare Cesarean and forceps delivery rates, and quality of pain relief, in first-time mothers undergoing induction of labor who receive neuraxial vs. IV/IM analgesia for early labor (cervical dilation < 4 cm).

Inclusion Criteria:

• induction of labor, nulliparity, > 36 weeks gestation, single gestation, vertex position, cervical dilation < 4 cm at first request for analgesia, desires neuraxial analgesia

Exclusion Criteria:

• chronic opioid therapy, acute opioid therapy, allergy to study drugs (hydromorphone, fentanyl, bupivacaine, lidocaine)