Does Epidural Anesthesia Increase the Cesarean Delivery Rate?
Abstract & Commentary
Synopsis: Epidural anesthesia is not associated with an increased cesarean delivery rate.
Source: Halpern SH, et al. JAMA 1998;280: 2105-2110.
To evaluate the effect of epidural analgesia on the incidence of cesarean delivery, Halpern and colleagues conducted a meta-analysis of 10 prospective, randomized trials enrolling 2369 patients. Half of these investigations were conducted in the United States. The outcomes of patients randomized to receive epidural anesthesia were compared to those women receiving parenteral opioids. The narcotics used included meperidine, fentanyl, and butorphanol, dosed as needed or by patient-controlled analgesia. The total rate of cesarean delivery did not differ between patients receiving an epidural (8.2%) or parenteral opioids (5.6%), nor was there a difference when the data were analyzed by parity or in the rate of cesarean delivery for dystocia. While the rate of instrumented deliveries was significantly higher in the epidural group, no difference was noted in instrumented deliveries performed for dystocia. The first stage of labor was, on average, 42 minutes longer in patients receiving an epidural while the second stage was 14 minutes longer. More patients in the epidural group required oxytocin, had a fever higher than 38°C, and experienced hypotension. Pain relief was significantly improved during labor and patient satisfaction was significantly higher with epidural anesthesia. Analysis of neonatal outcomes revealed significantly fewer Apgar scores of less than 7 at one and five minutes in the epidural group. No differences were noted in the incidence of fetal distress or meconium passage. Infants whose mothers had received epidural anesthesia were less likely to require naloxone or have a low umbilical artery pH. Neither method of pain relief was associated with serious neonatal problems.
Halpern et al conclude that epidural anesthesia is not associated with an increased cesarean delivery rate. While the length of labor is prolonged in women receiving an epidural, patient satisfaction and neonatal outcome are better than with opioid analgesia.
Comment by Steven G. Gabbe, MD
This important meta-analysis demonstrates the benefits of epidural anesthesia as compared to pain relief with opioids. Of note, four of the studies included in the meta-analysis were published in 1997 and used an epidural technique combining a local anesthetic with a narcotic, a method associated with a less dense motor block. The prolongation of the first and second stages of labor in patients receiving epidural anestheia, while statistically significant, does not appear to be of great clinical importance. Nor were there more instrumented vaginal deliveries for dystocia in these patients. In summary, epidural anesthesia was associated with significantly better pain relief than opioids and better neonatal outcomes.