Examining the Evidence
Q Does epidural early in labor lead to C-section?
<huc>A</huc> Not according to this study. When epidural analgesia was given at the patient’s first request, it did not increase the risk of cesarean or instrumental delivery or adverse effects. It also shortened the first stage of labor.
Details of the study
Nulliparous women in early labor were randomized to receive epidural analgesia at the first request (“early” group, about 2.4 cm cervical dilation) or “late” (group in which the epidural was initiated at a mean dilation of 4.6 cm). Analgesia in the late group was provided by parenteral meperidine (Demerol) until cervical dilation increased.
There were no differences in:
- Cesarean delivery rates, either overall or for failure to progress
- Use of oxytocin
- Incidence of maternal fever
- Neonatal outcome as measured by Apgar score
- Presence of meconium
Why is this study important? There has always been, and continues to be, controversy about epidural analgesia during labor and alleged adverse effects on progress and outcome of labor. Ohel and colleagues have added to the growing body of evidence on these alleged effects—or lack thereof.
Although recent studies have virtually eliminated epidural analgesia per se as an important or causative factor for intrapartum cesarean delivery, there is still some concern that early initiation may have other adverse effects.
What about other adverse effects?
A recent study by Wong et al1 drew the same conclusions as Ohel et al. However, the Wong study was criticized (a criticism with which I do not agree) for its use of a combined spinal-epidural technique, which was not thought to be representative of standard labor practice.
Ohel et al used a protocol that, by any definition, would be considered a typical epidural analgesia “cocktail.” Thus, it should lay to rest any further concerns about alleged adverse effects of early regional analgesia.
Induced and spontaneous labors were included. One potential criticism of this trial is the inclusion of both induced and spontaneous labors. Ohel et al acknowledged and addressed this concern, and provided separate analysis, including power analysis, for these 2 groups. The results were consistent.
Comply with her request
This investigation report was accompanied by a superb editorial,2 which concluded:
“…it is difficult to argue that epidural analgesia should be withheld from a woman who requests pain relief in labor. While such decisions should always be individualized, there should no longer be an arbitrary degree of cervical dilation before such a decision is considered.
“No longer should a patient be made to feel guilty about her wish for pain relief early in labor, powerless in her choices, or conflicted about the consequences of such a choice. Women should receive adequate pain relief when needed, as determined by the patient herself. What a concept—pain relief of real pain when requested.”
The author reports no financial relationships relevant to this article.