BMJ  2005;330:790 (2 April), doi:10.1136/bmj.330.7494.790-b

Letter

Early epidurals increase caesarean rate, meta-analysis shows

EDITOR—The study reported by Mayor in her news item uses the term "neuraxial analgesia" and claims that early epidurals do not increase the rate of caesarean deliveries.^{1 2} This is confusing as the study was not of early epidural analgesia, and the oxytocin augmentation rate of 75% at first analgesia makes for lack of generalisability.

The claim that women need not worry that early epidurals will lead to increased caesareans is false.³ This trial was about two methods of helping women with pain in early labour. In the so called epidural arm, on their first request for analgesia, women received intrathecal fentanyl, and in the narcotic arm, hydromorphone. On their second request, almost two thirds of women in both arms were 4 cm or more dilated. In the intrathecal "epidural" arm, they received low dose epidurals; in the narcotic arm, hydromophone.

This trial, as others that have contributed to the Cochrane meta-analysis,^{4 5} showed no increase in caesareans in the presence of epidural analgesia, but does not acknowledge that most women were in active labour at randomisation, when most will do well. Wong et al,² like Sharma et al, the major contributors to the Cochrane meta-analysis,⁴ have shown only that when women's pain in the latent phase is managed with intrathecal, narcotic, or other pharmacological or non-pharmacological means, an epidural in the active phase of labour does not increase the rate of caesareans.

The role of an early epidural in contributing to increases in caesarean rates has yet to be studied in an randomised controlled trials, but the sensitivity analysis in the Cochrane meta-analysis, after removing late randomisation studies, shows that early epidurals to more than double caesarean rates.

BC Women's Hospital, Vancouver, British Columbia, Canada V6H 3VJ mklein{at}interchange.ubc.ca

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Competing interests: None declared.

References

1. Mayor S. Epidurals do not lead to more caesarean sections, study shows. BMJ 2005;330: 383. (19 February.)[Free Full Text]
2. Wong CA, Scavone BM, Peaceman AM, McCarthy RJ, Sullivan JT, Diaz NT, et al. The risk of cesarean delivery with neuraxial analgesia given early versus late in labor. N Engl J Med 2005;352: 655-65.[Abstract/Free Full Text]
3. Camann W. Pain relief during labor. N Engl J Med 2005;352: 718-20.[Free Full Text]
4. Sharma SK, Sidawi JE, Ramin SM, Lucas MJ, Leveno KJ, Cunningham FG. Cesarean delivery: a randomized trial of epidural versus patient-controlled meperidine analgesia during labor. Anesthesiology 1997;87: 487-94.[CrossRef][ISI][Medline]
5. Howell CJ. Epidural versus non-epidural analgesia for pain relief in labour. Cochrane Database Syst Rev 2005;(1).

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Epidurals do not lead to more caesarean sections, study shows

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