Epidurals do not lead to more caesarean sections, study shows
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7488.383 (Published 17 February 2005) Cite this as: BMJ 2005;330:383
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Mothers would be best advised to read the full report before asking
for an early epidural. In the full report the authors admit that opiods,
the drug used in the 'control' group, is known to "decrease uterine
activity both in humans and in active labor", which would seem to make it
a very poor choice of comparison for finding out if an early epidural lead
to a greater chance of having a C-section.. Why not use non-medicated
mothers as controls?
The public reports also failed to mention that this particular study,
supported by the Department of Anesthesiology, Freiberg school of
Medicine, Northwestern University, was not 'blind', which means that
physicians who got to decide which mothers would be operated on and after
how long a wait, may well have been biased; possibly waiting longer in the
epidural group. Also the epidural used was not only an epidural, but a
spinal followed later on by an epidural, inmost cases when the mother had
indeed reached a more advanced level of dilation. In the small print the
authors of this study on epidural timing, admit to not having "adjusted
for different obstetrical providers and management styles", or "pattern of
oxytocin use" - all very pertinent factors. A recent study published in
the American Journal of Obstetrics and Gynecology, claimed that choice of
obstetrician is the most important contributing factor to C-sections. Also
not mentioned in all the reports circulated in the public media was the
very high rise in instrumental vaginal deliveries among the mothers in the
combined spinal/epidural group: 19.6% vs. 16% in the opiod group. Both
rates being very high - and very risky - when compared to earlier studies
showing much lower rates for forceps and vacuum extraction deliveries in
non-medicated mothers.
Most worrisome of all was the change in fetal heartbeats, described as:
"Prolonged, persistent variable and late fetal heart-rate decelerations,
which developed after 30 minutes following the first analgesic
intervention more often in the intrathecal-analgesia group" - the combined
epidural group. A very serious side-effect for most expectant mothers!
Bad as such ominous fetal heartbeats are for a fetus; their association
with the combined epidural is nothing new in the medical literature. The
largest study conducted on the combined spinal/epidural was in ’98 by Dr.
Gambling and co-workers at the famous Parkland Hospital – Americas’ number
one experimental ground for obstetrical procedures. Using 1223 woman
randomized to either continuous spinal epidural analgesia or boluses of
intravenous meperidine, (an opiod), 9 out of 616 mothers in the combined
spinal-epidural group were quickly operated on for fetal bradycardia with
heart rates falling dangerously low to less than 60 beats per minute and
lasting 60 seconds or longer. Parkland Hospital now cleverly 'avoids the
combined-spinal-epidural technique" according to the authors of the latest
issue of Williams' Obstetrics', but a mother reading about this new study
on the safety of o early epidural anesthesia would never know to do
likewise...
Competing interests:
Director of SAFE, the Society for Antenatel Fitness and Education, which promotes prenatal education.
Competing interests: No competing interests
The New England Journal article cited as news has misnamed the
treatment studied. It is not about epidural analgesia at all, but
intrathecal analgesia in nulliparous women followed by low-dose epidural
analgesia in the so-called epidural arm, compared with systemic
hydromorphone.
The study took place in a relatively low Cesarean study environment
(17.8 to 20.7%) employing virtually universal oxytocin augmentation. Care
seems to have been excellent.
Does this study have external validity for the usual place where
women receive care; less than one-to-one nursing, increasingly fetal
surveillance by central monitoring, or is it a case that in the rarefied
atmosphere of randomized controlled trials, women get excellent care
regardless of study arm?
These results cannot be used to make the claim, as stated in the
original publication and accompanying editorial, that a woman need not
fear that an epidural at 2cms will increase her chances for a Cesaarean
section. It is however an interesting study that needs replication in our
usual maternity environments.
Competing interests:
None declared
Competing interests: No competing interests
Early Epidurals NOT shown to be Cesarean Section Neutral
Given the continued dysinformation in the popular press and in the
medical news media, I write to further comment on validity of this study--
claiming that early epidurals or neuraxial analgesia does not increase the
rate of Cesarean section.
The reported study was not a study of early
epidural analgesia. Wong et al, (1) the editorialist (2) and the press,
report that women need not worry that an early epidural will lead to an
increased likelihood of Cesarean. This claim is unjustified by the
research reported. This trial was not about early epidural analgesia. It
was about two methods of helping women with the pain of early labor. In
the so-called epidural arm, at first request for analgesia, women got
intrathecal fentenyl; in the narcotic arm ,hydromorphone. On second
request for pain relief, two thirds of the women in both arms were >=4
cms dilated or in the active phase of labor. At this advanced state, in
the intrathecal-"epidural" arm they received a low dose epidural. In the
narcotic arm, they got hydromophone intramuscularly. This trial as
others(3) that have contributed to the Cochrane metaanalysis (4) showing
no increase in Cesarans in the presence of epidural analgesia, is
misleading because it does not report, even emphasize, that most women in
these trials were in the active phase of labor at point of randomization.
Wong(1), like Sharma, the major contributor to the Cochrane
metaanalysis,(3) has shown only that when women’s latent phase pain is
managed with intrathecal, narcotic or other pharmacological or non-
pharmacological means, an epidural in the active phase of labor does not
increase the Cesarean rate. The role of an early epidural in contributing
to Cesarean increase has yet to be studied in a clinical trial.
References
1.Wong CA, Scavone BM, Peaceman AM, et al. The Risk of Cesarean
Delivery with Neuraxial Analgesia Given Early versus Late in Labor. N Engl
J Med 2005;352(7):655-65.
2.Camann W. Pain Relief during Labor. N Engl J Med 2005;352(7):718-20.
3.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.[see comment]. Anesthesiology
1997;87(3):487-94.
4.Howell, CJ. -Epidural versus non-epidural analgesia for pain relief in
labour [Systematic Review]. Cochrane Database of Systematic Reviews
2005;(1).
Competing interests:
None declared
Competing interests: No competing interests