References
Epidural analgesia in labour and the risk of emergency caesarean: a retrospective observational study
Abstract
Background/Aims
A Cochrane review reported that epidural analgesia had no effect on the risk of emergency caesarean section; there was a discrepancy between these findings and the author's clinical observations, prompting the author to evaluate labour outcomes for women with and without epidural analgesia. The aim was to establish whether the author's clinical observations were supported by data.
Methods
A retrospective review of the outcomes of 200 labours with and without epidural analgesia was carried out, limited to women the author had personally cared for. A subsequent trust-wide analysis of labours was conducted to explore wider trends in analgesia and emergency caesarean section.
Results
In the personal review, epidural analgesia was associated with a more than two-fold increase in risk of emergency caesarean section, regardless of the underlying obstetric risk factors (from 14.7% to 36.4%). A similar trend was found across the trust.
Conclusions
Epidural analgesia in labour is associated with increased risk of an emergency caesarean section. Potential reasons for the discrepancy with the Cochrane review findings include differences in anaesthetic practice, timing and dilation at the time of receiving epidural analgesia, and evidence that women taking part in a randomised controlled trial experience better outcomes than those receiving routine care.
Worldwide, rising caesarean section rates are a major public health concern (Boerma et al, 2018). In the absence of a clear medical indication (including mental health), a caesarean section offers no benefit to mother and baby (World Health Organization, 2023). However, caesarean sections are associated with increased risk of infection, blood clots and bleeding in women, abnormal placentation and stillbirth in future pregnancies and transitory tachypnea of the newborn (Sandall et al, 2018).
The link between epidural analgesia in labour and increased risk of an emergency caesarean section has been debated for decades (Chestnut, 1997; Segal et al, 2000; Klein, 2006; Kotaska et al, 2006; Newnham et al, 2016). The often-quoted rationale for the increased risk of emergency caesarean section for women with epidural analgesia is that some women choosing epidural have an ‘intrinsically difficult and ultimately obstructed labor’ (Alexander et al, 2001). There is an argument that women with long latent stage and delays in the first stage of labour often experience fetal malposition and/or cephalopelvic disproportion causing excessively painful labours; therefore the cause of the increased risk of emergency caesarean section in these women is malposition and/or cephalopelvic disproportion rather than epidural analgesia (Wuitchik et al, 1989; Leighton and Halpern, 2002; Arulkumaran, 2012). However, this line of thinking is disputed (Lieberman et al, 2005).
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