SMFM Papers www.AJOG .

org

Maternal pulse pressure at admission is a risk factor for fetal

heart rate changes after initial dosing of a labor epidural:
a retrospective cohort study
Nathaniel R. Miller, MD; Rebecca L. Cypher, MSN; Peter E. Nielsen, MD; Lisa M. Foglia, MD

OBJECTIVE: To examine low maternal admission pulse pressure (PP) as a
risk factor for new onset postepidural fetal heart rate (FHR) abnormalities.
STUDY DESIGN: Retrospective cohort study of nulliparous, singleton,
vertex-presenting women admitted to labor and delivery after 37 0/7
weeks that received an epidural during labor. Women with a low
admission PP were compared with those with a normal admission PP.
The primary outcome was new onset FHR abnormalities defined as
recurrent late or prolonged FHR decelerations in the first hour after
initial dosing of a labor epidural.
RESULTS: New onset FHR abnormalities, defined as recurrent late
decelerations and/or prolonged decelerations, occurred in 6% of
subjects in the normal PP cohort compared with 27% in the low PP
cohort (odds ratio, 5.6; 95% confidence interval, 2.1e14.3; P <
.001). A multivariate logistic regression analysis generated an adjusted
odds ratio of 28.9 (95% confidence interval, 3.7e221.4; P < .001).
CONCLUSION: New onset FHR abnormalities after initial labor
epidural dosing occur more frequently in women with a low admis-
sion PP than those with a normal admission pulse. Admission PP
appears to be a novel predictor of new onset postepidural FHR
abnormalities.
Key words: intrapartum fetal heart monitoring, obstetric anesthesia,
pregnancy hemodynamics

Cite this article as: Miller NR, Cypher RL, Nielsen PE, et al. Maternal pulse pressure at admission is a risk factor for fetal heart rate changes after initial dosing of a labor
epidural: a retrospective cohort study. Am J Obstet Gynecol 2013;209:382.e1-8.

R egional anesthesia is the most

common labor pain management
tool in contemporary obstetric practice
6e30% respectively, depending on the
technique and dose of medication used.3-7
Contemporary medications, doses, and
maternal hypotension after initial dosing
of a labor epidural.
Initial dosing of a labor epidural af-
in the United States.1 Labor epidurals techniques for epidural placement are fects the hemodynamic profile by
have been implicated in some observa- associated with lower rates compared with altering the complex mechanisms the
tional studies to increase the risk of higher dosage techniques.8 body uses to generate and maintain
certain obstetric interventions and out- Limited information exists on ma- maternal blood pressure, uteroplacental
comes when compared with either no ternal and fetal characteristics that might blood flow, and fetal perfusion. De-
analgesia or no epidural. These risks be risk factors for the changes in creases in systemic vascular resistance
include maternal hypotension, operative maternal vital signs and FHR after and venous return, changes in circu-
vaginal delivery, maternal fever, a longer dosing of regional anesthesia.9,10 The lating catecholamine levels, and changes
second stage of labor, and cesarean de- hemodynamic effects of the labor epi- in uterine tone are all attributed to the
livery for fetal distress.2 dural have been described in patients incidence of both FHR abnormalities
In the 60 minutes after initial dosing of with assumed normal initial intravas- and maternal hypotension.13,14 During
regional anesthesia, the frequency of cular volume.11,12 Maternal vital signs these often abrupt and profound alter-
maternal hypotension and fetal heart rate have not been examined as indicators ations in hemodynamics intravascular
(FHR) changes range from 5e18% and for subsequent FHR abnormalities and fluid volume is a relative constant. This
physiologic premise is the basis for giv-
ing an intravenous (IV) fluid bolus
From the Department of Obstetrics and Gynecology, Madigan Army Medical Center, Joint Base
Lewis-McChord, Tacoma, WA. before the initial dosing of a labor
Received March 15, 2013; revised May 1, 2013; accepted May 22, 2013.
epidural as a buffer for these changes.
However, a recent Cochrane review of
The opinions or assertions contained herein are the private views of the authors and are not to be
construed as official or as reflecting the views of the Department of Defense. The investigators have this practice suggests that the incidence
adhered to the policies for protection of human subjects as prescribed in 45 CFR 46. of FHR abnormalities and maternal
The authors report no conflict of interest. hypotension are not reduced when com-
Presented as a poster during the 33rd annual meeting of the Society for Maternal-Fetal Medicine, pared with patients who do not receive
San Francisco, CA, Feb. 11-16, 2013. this prophylactic IV fluid bolus.8
Reprints not available from the authors. In healthy patients, surrogate clinical
0002-9378/$36.00 ! ª 2013 Mosby, Inc. All rights reserved. ! http://dx.doi.org/10.1016/j.ajog.2013.05.049 indicators of intravascular fluid volume
such as mean arterial pressure, heart

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FIGURE 1
Flow of subject identification and inclusion in study
Miller. Maternal admission pulse pressure. Am J Obstet Gynecol 2013.
rate, and urine output are commonly
used. Pulse pressure (PP) is a hemody-
namic parameter calculated by sub-
tracting the diastolic blood pressure
(DBP) from the systolic blood pressure
(SBP).15 The use of PP as perhaps one of
the earliest clinical predictors of intra-
vascular volume status is highlighted in
both observational and experimental
trauma literature. In a series of 28 pa-
tients, PP was identified as the only
distinguishing prehospital vital sign
characteristic associated with a higher
likelihood of death follow traumatic
injury.16 This observation was supported
by a more robust observational study17
and in physiologic simulators of central
blood volume loss.18 Convertino and
colleagues18 demonstrate a significant
correlation between stroke volume (SV)
and PP as well as a linear relationship
between PP and central blood volume
reductions with no differences in mean
arterial pressure (MAP). PP has also
been demonstrated as a clinical esti-
mator of the intravascular fluid volume
in ambulatory dialysis patients.19
Decreased intravascular volume, de-
fined as a PP <45 mm Hg, may be a
risk factor for FHR abnormalities and
maternal hypotension after the initial
dosing of a labor epidural. Our primary
objective is to determine whether a low
admission PP increases the risk of post-
epidural FHR abnormalities.
M ATERIALS AND M ETHODS
This is a retrospective cohort study,
performed with institutional review
board approval (IRB # 211070) in a large
military teaching medical center. We
defined a value of <45 mm Hg as a low
PP. It has been observed that in other-
wise healthy nonpregnant patients SV is
about 1.7 times the PP17,18 and in healthy
pregnant women an increase in SV after
38 weeks EGA to approximately 100 mL/
min has been described.20 Based on this
OCTOBER 2013 American Journal of Obstetrics & Gynecology
SMFM Papers
information we extrapolated that a
normal PP would be about 60 mm Hg at
term and subsequently selected a value of
<45 mm Hg as “low” and a PP of "45
mm Hg as “normal.”
For the power analysis we assumed an
incidence of 18% (the average of re-
ported rates) for postepidural FHR ab-
normalities in subjects with a normal PP
(control cohort). To detect a 2-fold in-
crease in new onset FHR abnormalities
in the low PP cohort and assuming 80%
power and an alpha of 0.05 a total sample
size of 190 subjects was required.
To identify 95 subjects with a low
admission PP who also met inclusion
criteria (exposure cohort) we had to re-
view all birth records for a 6 month pe-
riod (September, 2010eFebruary 2011).
There were a total of 1008 deliveries
during that 6 month period, with 258
subjects that fulfilled inclusion criteria
and had a normal admission PP. We
generated a random number table and
used permuted blocks of 4 to select 95 of
these subjects to use as the control cohort
(Figure 1). Inclusion criteria were as fol-
lows: age 18 years and older, nulliparity,
singleton, vertex-presenting, greater than
37 0/7 weeks, and received a labor
epidural.
Demographic, clinical, and laboratory
data was extracted from the electronic
medical record (EMR). These data
included age in years, Estimated gesta-
tional age (EGA) calculated in weeks,
body mass index (BMI kg/m2, admis-
sion diagnosis, cervical dilation, Bishop
score, maternal comorbidities, and pa-
tient reported race, gravidity, and parity.
We also collected data about the
placement and initial dosing of the
labor epidural. Anesthesia records were
reviewed to record the medication con-
centration and dose used for the initial
epidural bolus, timing, and type of IV
fluid bolus before placement and labor
status at time of epidural request. All the
above information was a priori identified
as potential confounders to the inter-
pretation of our primary outcome and
is part of the routine documentation in
our EMR.
The primary outcome, new onset
FHR abnormalities, was defined as
recurrent late decelerations and/or
382.e2
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prolonged decelerations in the first 60

minutes after initial dosing of labor TABLE 1
epidural using current National Institute Admission characteristics
of Child and Human Development PP ‡45 mm Hg PP <45 mm Hg
(NICHD) electronic fetal monitoring Characteristic (n [ 95) (n [ 95) P value
definitions (FHM).21 The 60 minutes Age, y 24.4 # 4.8 24.6 # 4.3 .70
before and after epidural dosing were EGA, wks 39.3 # 1.1 39.5 #1.1 .32
divided into discrete 20 minute seg-
Gravidity .94
ments. The fetal tracings were re-
viewed by 2 Association of Women’s G1 63 (66) 65 (68)
Health, Obstetric, and Neonatal Nurses G2 24 (25) 23 (24)
(AWHONN) FHM instructor trainers " G3 8 (8) 7 (7)
who were blinded to all subject infor-
mation, purpose of the study, and Race .26
admission vital signs. The reviewers used White 64 (67) 68 (71)
a data collection sheet to describe the African American 9 (10) 8 (8)
FHR baseline, variability, the presence or
Hispanic 1 (1) 0 (0)
absence of accelerations, presence or
absence of decelerations, the type of Asian 8 (8) 2 (2)
decelerations, and whether the de- Other 13 (14) 17 (18)
celerations were recurrent. Contraction
Admission labor diagnosis .67
frequency, calculated Montevideo units
and uterine resting tone (if applicable) Spontaneous 57 (60) 54 (57)
were also described by these reviewers. If Induction 38 (40) 31 (43)
there was a discrepancy between the first
Maternal comorbidities .26
2 reviewers, the tracing was reviewed by
a third AWHONN FHM instructor Pregestational diabetes 0 (0) 2 (2)
trainer (blinded in the same fashion). Gestational diabetes 10 (11) 10 (11)
The congruent interpretation was used in Chronic hypertension 7 (7) 3 (3)
the assessment of the primary outcome.
Proteinuria 3 (3) 1 (1)
We examined several secondary out-
comes. New onset maternal hypotension Gestational hypertension 14 (15) 9 (9)
was defined as an absolute SBP <100 Preeclampsia 7 (7) 1 (1)
mm Hg or a "20% decrease in SBP,
BMI, kg/m2 32.2 # 5.2 29.3 # 4.9 < .001
treatment for hypotension or FHR
changes defined as extra measures Tobacco use 8 (8) 10 (11) .28
(multiple position changes, supplemen- Cervical dilation, cm 3 # 1.5 3 # 1.7 .56
tal oxygen, postepidural fluid bolus, Bishop score 8#3 8#3 .76
vasoconstrictor administration, or toco-
Admission hematocrit, % 36.9 # 3.4 36.4 # 3.5 .40
lytic administration), length of the stages
Data are mean # standard deviation or n (%) unless otherwise specified.
of labor, diagnosis of amnionitis, 1 and 5
BMI, body mass index; EGA, estimated gestational age; PP, pulse pressure.
minute APGAR scores, birthweight, and
Miller. Maternal admission pulse pressure. Am J Obstet Gynecol 2013.
mode of delivery. If operative delivery
occurred, indication for the mode of
delivery was included.
Data were analyzed using PASW R ESULTS a higher average admission BMI than
statistics for Windows (version 18.0; From the 1008 birth records reviewed, those admitted with a low PP (32.2 # 5.2
SPSS Inc, Chicago, IL). The appropriate we identified 95 who met inclusion vs 29.3 # 4.9, P < .01).
t test for continuous variables and the criteria and had a low admission PP. Over The total volume of IV fluid given
appropriate c2 test for comparing the same time period, 258 patients from admission and the amount given as
proportions between the groups were were admitted with a normal PP and a preload IV bolus was similar between
performed. A planned multivariate met inclusion criteria. We selected 95 groups. The number of subjects on
logistic regression was performed for control subjects as previously described oxytocin at the time of epidural dosing,
the primary outcome and for the sec- (Figure 1). Admission characteristics be- frequency of cervical examinations, and
ondary outcome of new onset maternal tween the cohorts were similar (Table 1). indwelling bladder catheter placement
hypotension. Subjects with a normal admission PP had within the first hour postepidural were

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TABLE 2
Pre and postepidural characteristics
Characteristic PP ‡45 mm Hg (n [ 95) PP <45 mm Hg (n [ 95) P value
Admission to request, h 5.9 # 5.8 7.4 # 5.2 .054
Fluid from admission to request, mL 995 # 886 925 # 766 .56
Cervix at request 4.1 # 1.4 4.3 # 1.3 .26
Request to placement, min 40 # 22 43 # 22 .37
Narcotics before epidural placement 30 (32) 32 (34) .78
Epidural medication (concentration) .54
Ropivacaine (0.2%); fentanyl (2 mcg/cc) 79 (83) 78 (82)
Initial bolus, mL 6.4 # 1.7 6.3 # 1.6
Lidocaine (1.5%); fentanyl (2 mcg/cc) 6 (6) 11 (12)
Initial bolus, mL 5#0 4.6 # 0.5
Lidocaine (1.5%) 4 (4) 3 (3)
Initial bolus, mL 5#0 5#0
Fentanyl (2 mcg/cc) 5 (5) 3 (3)
Initial bolus, mcg 90 þ 22 83 þ 28
Bupivicaine (0.25%) 1 (1) 0 (0)
Initial bolus, mL 1 —
Received preepidural bolus 92 (97) 94 (99) .31
Volume of bolus 918 # 231 968 # 160 .083
Type of fluid .23
Lactated ringers 88 (93) 93 (98)
Hespan 4 (4) 1 (1)
None 3 (3) 1 (1)
Time for placement, min 17 # 12.5 14 # 6.4 .02
Oxytocin during epidural 38 (40) 52 (55) .059
Foley placed in 1st hour 63 (66) 69 (73) .35
Cervical exam in 1st hour 8 (8) 10 (11) .62
Extra measures initiated 27 (28) 61 (64) < .001
Multiple position changes 20 (21) 59 (62) < .001
Supplemental oxygen 12 (12) 40 (42) < .001
Intravenous fluid bolus 10 (11) 28 (30) < .001
Vasoconstrictor or tocolytic 6 (6) 16 (17) .02
Data are mean # standard deviation or n (%) unless otherwise specified.
PP, pulse pressure.
Miller. Maternal admission pulse pressure. Am J Obstet Gynecol 2013.

all similar. Total time to place and dose
the epidural was 14 # 6.4 minutes in
the low PP vs 17 # 12.5 minutes for
the normal PP cohort (P ¼ .02). Extra
measures or additional interventions
were provided more frequently to those
subjects with a low PP than those with a
normal PP. The type and dose of epi-
dural medication bolused were similar
between groups (Table 2).
Admission PP, SBP, and DBP were
different between the 2 cohorts (Table 3).
At the time of epidural request and at the
time of epidural timeout there were no
differences in any of the vital sign pa-
rameters. However, after initial dosing of
the epidural bolus, differences in vital
signs were observed. The low PP group

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had significantly lower SBP and PP for

the 60 minutes after initial epidural TABLE 3
dosing. Figure 2 describes the SBP from Maternal vital signs
admission until 60 minutes after the Variable PP ‡45 mm Hg PP <45 mm Hg P value
initial dosing of the labor epidural. This Admission n ¼ 95 n ¼ 95
shows that despite similar mean SBP at
PP 55 # 10.8 40 # 3.6 < .001
time of epidural request and timeout
there was a significant difference in the SBP 132 # 15 119 # 10.0 < .001
postepidural SBP values. The low PP DBP 76 # 10.2 79 # 9.7 .037
cohort had significantly lower average MAP 95 # 10.9 93 # 9.7 .15
MAP at 20-40 minutes. DBP and heart
HR 89 # 15.1 91 # 15.5 .24
rate did not differ during the 60 minutes
after initial epidural dosing. Epidural request n ¼ 72 n ¼ 78
New onset FHR abnormalities, defined PP 57 # 13.2 55 # 11.3 .3
as recurrent late decelerations and/or
SBP 130 # 18.2 128 # 14.6 .58
prolonged decelerations, occurred in 6%
of subjects in the normal PP cohort DBP 73 # 11.5 74 # 11.5 .53
compared with 27% in the low PP cohort MAP 92 # 12.8 92 # 11.3 .97
(odds ratio [OR], 5.6; 95% confidence HR 83 # 14.6 84 # 15.3 .67
interval, 2.1e14.3; P < .001). The
adjusted OR was 28.9 (95% confidence Epidural timeout n ¼ 70 n ¼ 88
interval, 3.8e221.4; P < .001). The sec- PP 54 # 11.3 54 # 11.6 .99
ondary outcome of new onset maternal SBP 133 # 13.3 130 # 11.0 .23
hypotension was not statistically signifi-
DBP 79 # 11.7 77 # 11.0 .20
cant for either the crude or adjusted ORs
(Table 4). Adjusted ORs for new onset MAP 97 # 11.7 95 # 10.3 .28
FHR abnormalities and new onset HR 91 # 14.6 90 # 15.4 .66
maternal hypotension were calculated
0-20 min after epidural n ¼ 95 n ¼ 95
controlling for maternal age, estimated
gestational age, BMI, cervical dilation at PP 51 # 9.3 48 # 9.2 .041
admission, maternal comorbid condi- SBP 120 # 15.9 115 # 13.0 .027
tions, tobacco use, admission hematocrit, DBP 69 # 11.5 67 # 9.9 .27
amount of IV fluids before epidural
MAP 86 # 12.3 83 # 10.5 .74
request, cervical dilation at time of
epidural request, epidural medication HR 89 # 15.1 90 # 17.0 .53
bloused, time for epidural placement, use 20-40 min after epidural n ¼ 87 n ¼ 92
of oxytocin at epidural placement, cervix
PP 52 # 9.8 48 # 8.9 < .001
examination within the hour after place-
ment, urinary foley catheter placement SBP 119 # 15.3 113 # 10.8 < .001
within the hour after placement, admis- DBP 67 # 11.7 65 # 8.4 .18
sion SBP, DBP, and heart rate. MAP 84 # 12.1 81 # 8.3 .035
No differences were observed in the
HR 85 # 14.9 87 # 16.8 .37
overall length of labor, the length of each
stage of labor, time from epidural 40-60 min after epidural n ¼ 87 n ¼ 92
placement to delivery, mode of delivery, PP 54 # 11.1 49 # 9.1 < .001
or delivery outcomes (Table 5).
SBP 120 # 16.0 115 # 12.9 .03
C OMMENT DBP 66 # 9.4 65 # 9.1 .99
Our results identify an admission PP of MAP 84 # 10.1 82 # 9.6 .27
<45 mm Hg as a risk factor for new HR 85 # 16.1 88 # 17.0 .28
onset postepidural FHR abnormalities.
Data are mean # standard deviation.
This increased risk is even more pro-
DBP, diastolic blood pressure; HR, heart rate; MAP, mean arterial pressure; PP, pulse pressure (SBP-DBP); SBP, systolic blood
nounced after controlling for con- pressure.
founders. However, a low admission PP Miller. Maternal admission pulse pressure. Am J Obstet Gynecol 2013.
does not appear to increase the risk of

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FIGURE 2
Trend in mean systolic blood pressure over time
Squares represent mean systolic blood pressure at that point in time; Error bars indicate standard
error. Dashed line represents subjects with an admission PP "45 mm Hg and the solid line those
with a PP <45 mm Hg.
PP, pulse pressure.
Miller. Maternal admission pulse pressure. Am J Obstet Gynecol 2013.
maternal hypotension after initial bolus
of the labor epidural. The absence of a
relationship between maternal hypo-
tension and FHR abnormalities is seen
clinically and observed in many studies
on this topic.3-7,12,22 Regional differences
between systemic and uterine blood flow
at various points during pregnancy and
in response to endogenous and exoge-
nous substances is well described.23 The
gravid uterus demonstrates a significant
drop in vascular resistance24 and rise in
blood flow25 most evident by the third
trimester. Ultimately the result is a low-
resistance, largely maternal pressure
dependent exchange circuit between the
placental and fetal vasculature.23 The
uterus has only a limited ability to
autoregulate blood flow. Despite normal
systemic blood pressures, uterine and
fetal perfusion pressures are especially
vulnerable in those patients with a
decreased intravascular volume because
of the blunting of sympathetic control of
vascular tone after the initial dosing of
the labor epidural. This may explain why
the incidence of FHR abnormalities and
maternal hypotension are not the same
and why FHR abnormalities have been
described in the absence of maternal
hypotension.
We further observed that a low
admission PP is associated with an
increased number of maternal position
changes, use of supplemental oxygen, IV
fluid bolus, and administration of toco-
lytics and vasoconstricting medications
even in the absence of maternal hypo-
tension or FHR abnormalities. For cases
when maternal hypotension and or FHR
abnormalities are observed these in-
terventions occur because of recognition
of the abnormality. Interventions were
performed in a single case from the
normal PP cohort and 11 cases from the
low PP cohort without overt evidence of
abnormalities meeting the definitions
used. The timing of, and reason(s) for
the interventions were not captured by
the chart review conducted.
Efforts to identify factors that increase
risk for hypotension and FHR abnor-
malities after regional anesthesia are
limited. Maternal factors of age greater
OCTOBER 2013 American Journal of Obstetrics & Gynecology
SMFM Papers
than 32 years and severity of pain just
before combined spinal-epidural were
prospectively described by Nicolet
et al.10 Gaiser et al9 described retro-
spectively preexistent fetal variable de-
celerations and a high fetal station as risk
factors after intrathecal dosing. No such
studies have addressed this topic in pa-
tients receiving an epidural for labor
pain management.
Although parameters of maternal he-
modynamics have been described in pa-
tients receiving a labor epidural11,12 they
have not been examined as potential risk
factors for postepidural FHR changes or
hypotension. In healthy normotensive
parturients, it was demonstrated that
intervillous blood flow is not affected by
initial dosing of a labor epidural.26
Observational studies and experimental
studies consistently report subject co-
horts with similar baseline demographics
and maternal hemodynamics.3-7,12,22
Our study is unique because we com-
pared cohorts of woman based on a dif-
ference in maternal vital signs.
We have attempted to overcome the
limitations of the retrospective cohort
design by collecting and controlling for
previously described confounders such
as maternal age, type and dose of anes-
thesia, as well other potential con-
founders including BMI, maternal
comorbid conditions, use of oxytocin,
and total IV fluids received before
epidural bolus. Specific documentation
on patient positioning for admission vi-
tal signs and throughout their labor
course was not available. Woman pre-
senting to our Labor and Delivery unit
are first assessed in a triage unit. It is
standard practice for patients to be in
semirecumbent position with left lateral
displacement for their first set of vital
signs. Although the SBP and DBP values
may change to a significant degree based
on patient position, PP remains rela-
tively constant.15 Our design ensured
unbiased and blinded review of FHR
tracings which lends strength to our
overall findings as does the uniform and
contemporary use of published FHR
descriptive definitions.
PP was chosen as the vital sign dis-
tinguisher because of its demonstrated
use as the best peripheral correlate of
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TABLE 4
New onset fetal heart rate abnormalities and maternal hypotension
Admission Admission
PP >45 mm PP <45 mm
Variable Hg (n [ 95) Hg (n [ 95) OR (95% CI) P value Adjusteda OR P value
Fetal heart rate abnormalities 6 (6) 26 (27) 5.6 (2.1e14.3) < .001 28.9 (3.8e221.4) < .001
New onset maternal hypotension 20 (21) 24 (25) 1.3 (0.6e2.5) .49 1.6 (0.6e 4.3) .36
Data are n (%).
CI, confidence interval; OR, odds ratio; PP, pulse pressure.
a
Adjusted for maternal age, estimated gestational age, body mass index, cervical dilation at admission, maternal comorbid conditions, tobacco use, admission hematocrit, amount of intravenous
fluids before epidural request, cervical dilation at time of epidural request, time for epidural placement, epidural medication and dose bolused, use of oxytocin, cervix examination during hour after
placement, urinary foley catheter placement during hour after placement, admission systolic blood pressure, diastolic blood pressure, and heart rate.
Miller. Maternal admission pulse pressure. Am J Obstet Gynecol 2013.

central blood volume over SBP, DBP, and increase in PP and SBP from admission signs even with lower intravascular vol-
even MAP. Admission demographics in to epidural request in the low admission umes.17,18 The IV fluid volumes received
our study demonstrate values similar to PP cohort to values similar to the normal were similar between cohorts, but
those in the trauma literature, namely, PP cohort as an example of this this modest increase in intravascular
patients with a lower PP have lower SBP complexity (Table 2 and Figure 2). This volume may have augmented the com-
and DBP than those with normal a PP change may be evidence of a confounder pensatory mechanisms attempting to
but similar values for MAP.16-18 The not identified in our study design that maintain normal pressure in the low PP
process of generating and maintaining further distinguishes the 2 cohorts. cohort, ultimately masking the overall
maternal blood pressure is complex and However, this may be evidence of the low intravascular volume. The blunting
multifactorial; it is difficult to study any drive for hemodynamic homeostasis and of these compensatory mechanisms
individual aspect in isolation. We cite the the body’s ability to sustain normal vital because of the sympathectomy after the
dosing of the labor epidural unmasks
this low intravascular volume and is a
TABLE 5 likely explanation for the profound drop
Labor and delivery outcomes in PP, SBP, and even MAP in the low PP
Admission Admission cohort compared with the normal PP
Variable PP >45 mm Hg (n [ 95) PP <45 mm Hg (n [ 95) P value cohort.
1st stage labor, h 15.4 # 8.0 14.7 # 6.8 .52 Notably we did not observe an in-
crease in the overall cesarean delivery
Active labor, h 8.1 # 4.3 7.7 # 4.5 .56
rate or a difference in the number of
2nd stage labor, h 1.8 # 1.8 1.4 # 1.0 .68 cesarean deliveries performed for ab-
3rd stage labor, min 5.6 # 4.3 5.8 # 5.3 .76 normal FHR tracings in the low admis-
Total length of labor, h 17 # 8.3 16 # 6.6 .33 sion PP group. Although the overall
objective labor and delivery outcomes
Epidural to delivery, h 8.4 # 4.3 8.7 # 8.7 .66
were not different, during the 60 minutes
Fetal birthweight, gm 3431 # 531 3364 # 407 .40 after epidural bolus we observed resus-
1 min APGAR 7.9 # 1.3 8.1 # 1.4 .38 citative interventions being used more
5 min APGAR 8.9 # 0.3 8.9 # 0.2 .42 frequently in the patients with a low
admission PP. This was observed even
Chorioamnionitis 10 (11) 8 (8) .32
in patients who did not manifest
Mode of delivery .39 overt postepidural hypotension or fetal
SVD 72 (76) 73 (77) heart rate abnormalities. Commenting
CD 18 (19) 21 (22)
on the effect of these interventions
on a patient’s overall birth experience
Forceps 4 (4) 1 (1) is beyond the scope of this research
Vacuum 1 (1) 0 (0) design. However, we speculate that pre-
Data are mean # standard deviation or n (%) unless otherwise specified. epidural interventions performed for
CD, cesarean delivery; PP, pulse pressure; SVD, spontaneous vaginal delivery. women at risk may avoid the potentially
Miller. Maternal admission pulse pressure. Am J Obstet Gynecol 2013. anxiety provoking experience of mul-
tiple providers quickly implementing

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intrauterine resuscitation efforts after
the dosing of a labor epidural.
An admission PP <45 mm Hg confers
an increased odds of abnormal fetal
heart changes postepidural independent
of maternal pre- and postepidural vital
signs. Studies using noninvasive assess-
ments of intravascular volume in a pro-
spective manner would be helpful to
confirm our findings, and validate PP as
a surrogate for intravascular volume in
the laboring parturient by describing the
relation of PP to SV and cardiac output.
These studies may also aide in refining
the threshold of 45 mm Hg we describe
through the aid of a receiver operator
characteristic curve. Women identified
with this risk factor may benefit from
prophylactic strategies tailored to them.
Although the Cochrane review con-
cluded that preepidural boluses were
not effective in preventing new onset
fetal heart rate abnormalities, subjects
included in that review were not strati-
fied by PP. In clinical practice, patients
with a PP <45 mm Hg may be candi-
dates for higher volumes of IV fluid
administration from the time of labor
admission,27,28 or a larger preepidural
fluid bolus to make up for the intravas-
cular deficit. In addition, this cohort may
benefit from an intramuscular vaso-
constricting agent, like ephedrine, at the
time of epidural bolus.29 Randomized
clinical trials involving various volumes
of preepidural fluid boluses, rates of fluid
maintenance, and/or prophylactic vaso-
constricting agents for patients with a
low PP are warranted based on our data,
to determine whether these FHR ab-
normalities can be minimized, if not
prevented. - 497-501; discussion 502-493.
ACKNOWLEDGMENT
We thank Ms Samantha Thomas for her
invaluable assistance with fetal heart rate
tracing review.
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