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Early versus late initiation of epidural analgesia for labour

640_Pregnant_Gas.jpgEpidural analgesia involves the injection of medication just outside the spinal column. It is an effective form of pain relief during labour. The intensity of the pain increases as labour progresses. Epidural analgesia is an invasive procedure with side effects and more rarely complications. Reported side effects include muscle weakness, nausea, shivering, itching and headache. Epidural analgesia with low concentration infusions of bupivacaine has been shown to not increase the incidence of caesarean section but may increase the incidence of instrumental vaginal delivery and the duration of second stage of labour (Sia 2004). This Cochrane systematic review summarised the best available evidence (published before 12 February 2014) regarding the effectiveness and safety of early initiation versus late initiation of epidural analgesia for both spontaneous and augmented labour. Our meta-analysis involved nine randomised controlled studies with a total of 15,752 women giving birth to their first baby and found no differences in the risk of caesarean section and instrumental birth with early initiation versus late initiation of epidural analgesia for pain relief during labour. Although the effects of early or late initiation of epidural analgesia on the duration of the second stage of labour are similar, we are unable to rule out early initiation leading to an appreciably shorter duration of labour. There was a lot of variation (heterogeneity) between the results of the studies for the duration of the first stage of labour. For the baby, Apgar scores and cord pH were not different. We conclude that it would appear to be advantageous to initiate epidural analgesia for labour early, when requested by the woman.
The studies varied in the definition of early initiation and late initiation of epidural analgesia. Early initiation is typically defined as with cervical dilatation of less than 4 cm to 5 cm, and late initiation with cervical dilatation of 4 cm to 5 cm or more. The dose, concentration and technique of epidural analgesia also varied between the studies. The groups randomised to receive late initiation of epidural analgesia differed in the analgesia they received before the epidural analgesia.

Citation: Sng BL, Leong WL, Zeng Y, Siddiqui FJ, Assam PN, Lim Y, Chan ESY, Sia AT. Early versus late initiation of epidural analgesia for labour. Cochrane Database of Systematic Reviews 2014, Issue 10. Art. No.: CD007238. DOI: 10.1002/14651858.CD007238.pub2

Hepatitis B virus vaccine for People Living With HIV/AIDS

Manual vs. Electric toothbrushes | Manual toothbrush| Electric toothbrush Study Question
This review seeks to determine whether vaccine for hepatitis B virus is effective in protecting people who have HIV against hepatitis B virus infection. It also seeks to determine if the vaccine is safe in people living with HIV.

Hepatitis B virus infection can be acquired through contact with body fluids of infected people. Hepatitis B virus infection manifests with fever, yellowness of the eyes, abdominal pain and fatigue, but it can also be without symptoms especially in long standing infections. It can cause a persisting infection which can lead to liver complications and death. Hepatitis B virus infection and HIV infection are common in poorer countries and in these countries vaccines are not readily available. People living with HIV may not respond well to hepatitis B virus infection because of the weak ability for their bodies to develop resistance.

Study Characteristics
Our search for eligible papers was updated in August 2014 and we found one trial with 26 adult participants in Spain. The study sought to test if hepatitis B virus vaccine was better than placebo in preventing PLHIV from getting hepatitis B.

Key Results
The single study in this review showed improved immunity against hepatitis B among people living with HIV and taking antiretroviral therapy at 12 months. This immunity was lost once they stopped taking antiretroviral therapy. No side-effects were reported.

Quality of Evidence
The quality of evidence was assessed as very low.

Citation: Okwen MP, Reid S, Njei B, Mbuagbaw L. Hepatitis B vaccination for reducing morbidity and mortality in persons with HIV infection. Cochrane Database of Systematic Reviews 2014, Issue 10. Art. No.: CD009886. DOI: 10.1002/14651858.CD009886.pub2

The effect of taking antimalarial drugs routinely to prevent malaria in pregnancy

Description: Description: increases the risk of malaria and this is associated with poor health outcomes for both the mother and the infant, especially during the first or second pregnancy. For this reason, women are encouraged to try and prevent malaria infection during pregnancy by sleeping under mosquito bed-nets, and by taking drugs effective against malaria throughout pregnancy as chemoprevention.

This Cochrane Review looked at all drug regimens compared to placebo. The review authors sought to summarise and quantify the overall effects of chemoprevention. Seventeen trials were included, all conducted between 1957 and 2008, and all but two in countries of Africa.

For women in their first or second pregnancy, malaria chemoprevention prevents moderate to severe anaemia (high quality evidence); and prevents malaria parasites being detected in the blood (high quality evidence). It may also prevent malaria illness. We don't know if it prevents maternal deaths, as this would require very large studies to detect an effect.

In their infants, malaria chemoprevention improves the average birthweight (moderate quality evidence), and reduces the number of low birthweight infants (moderate quality evidence). We are not sure if chemoprevention reduces mortality of babies in the first week, month and year, as again studies would need to be very large to show these effects.

Citation: Radeva-Petrova D, Kayentao K, ter Kuile FO, Sinclair D, Garner P. Drugs for preventing malaria in pregnant women in endemic areas: any drug regimen versus placebo or no treatment. Cochrane Database of Systematic Reviews 2014, Issue 10. Art. No.: CD000169. DOI: 10.1002/14651858.CD000169.pub3

Healthcare interventions for consumers/public
The Cochrane Collaboration, is a not for profit organisation which produces systematic reviews on the effects of healthcare interventions. These reviews are published in an online database, The Cochrane Library monthly.

What is a systematic review?
A systematic review asks a specific research question about a particular healthcare intervention in a clearly defined group of people with a health condition or problem. These reviews summarise the results of healthcare studies and provides the evidence on the effectiveness of the interventions. Systematic reviews are complex and depend on what clinical trials have been conducted, the quality of the trials and the health outcomes that were measured. The review authors combine the numerical data about the effects of the treatment and the authors assess the benefits and harms for the specific treatment.1

For more information about what consumers can and cannot get from systematic reviews, please visit the Cochrane Consumer website.

The South African Cochrane Centre which is part of the Cochrane Collaboration, will publish consumer summaries monthly as listed below. Should you require information for a specific health condition please go to and search for the information you require or alternatively contact


1. Cochrane Consumer Network ( Accessed 17 August 2012

For more information, contact the South African Cochrane Centre on (021) 938 0834 or email
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Last updated:
6 November, 2014
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