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LETTERS TO THE EDITOR

Epidural Analgesia and Cesarean Delivery: What is the Relationship?

Department of Anaesthesia Sunnybrook and Women’s College Health Sciences Centre University of Toronto Toronto, Ontario, Canada M4N 3M5

The article by Fogel et al. (1) is an important contribution to the topic of epidural analgesia and cesarean delivery. Unfortunately, they seemed to have missed the opportunity to reveal some very important information. Selected demographics, such as diabetes and pregnancy-induced hypertension, are reported; however, details of labor, such as duration of stages and oxytocin use, are not.

Although the authors report the cesarean rate for nulliparous dystocia (no change), they do not report any other information (including epidural rate), comparing multiparous with nulliparous patients despite large numbers of nulliparous patients available for analysis (961 before versus 1205 after). This omission makes the reported cesarean rate uninterpretable.

The authors state that most of the care was given by rotating residents, albeit closely supervised by staff who did not change during the nearly 2.5 yr of the study. Nevertheless, this is no assurance that there was standardization of obstetrical practice.

Although I would like to believe the results shown in their article, a complete unbeliever could claim that perhaps increases in cesarean rate caused by epidurals were masked by decreases in the rate due to changes in obstetrical practice. If further details regarding labor and obstetrical management had been presented, it would be much easier to refute this claim.

References

1. Fogel ST, Shyken JM, Leighton BL, et al. Epidural labor analgesia and the incidence of cesarean delivery for dystocia. Anesth Analg 1998;87:119–23.[Abstract/Free Full Text]

Response

Department of Anesthesiology Washington University School of Medicine St. Louis, MO 63110-1093 Department of Anesthesiology Allegheny University Hospital for Women Philadelphia, PA 19131-1696

We appreciate Dr. Tarshis’ comments and interest in our report (1). The primary reason we performed our study (1) was to test the inverse of Thorp’s hypothesis (2,3), i.e., a large increase in labor epidural use would be associated with an increase in dystocia cesarean delivery. We successfully refuted this theory in a large, stable patient population with stable obstetric attending staff and policies. In fact, obstetric staff changes determined the start and end dates of our study. Among patients delivering before epidural analgesia was available, the dystocia (3.0%) and total (9.1%) cesarean delivery rates were quite low. In fact, these rates were among the lowest in Missouri at the time. It is not likely that changes in obstetric practice could have decreased these rates enough to counterbalance a cesarean-increasing effect of epidural analgesia. In addition, our results agree with those of Johnson and Rosenfeld (4), Lyon et al. (5), and Gribble and Meier (6). It is highly unlikely that concurrent, unsuspected changes in obstetric practice coincided with large changes in epidural use in all four studies.

As in many retrospective studies, there were undesirable deficiencies in our database. We were not able to separate patients in the after-group by both parity and epidural status. Because nulliparous patients have higher rates of both cesarean delivery and epidural use, not being able to separate After-Epidural and After-noEpidural patients by parity could have magnified the reported difference between these groups. Nonetheless, our results are similar to those of both Lyon et al. (5) and Gribble and Meier (6), who did separate patients by parity. We practice in an era in which third-party payor denials of epidural labor analgesia are justified as efforts to "save" women from cesarean delivery. Thus, we believe that it is important to compare our After-Epidural and After-noEpidural groups and to summarize the published and unpublished results of previous authors to emphasize that association does not prove causation. Women predestined to cesarean delivery request epidural analgesia much more frequently than women who deliver vaginally because dysfunctional labor hurts. Providing effective labor pain relief need not change a hospital’s cesarean delivery rate.

References

1. Fogel ST, Shyken JM, Leighton BL, et al. Epidural labor analgesia and the incidence of cesarean delivery for dystocia. Anesth Analg 1998;87:119–23.
2. Porreco RP, Thorp JA. The cesarean birth epidemic: trends, causes, and solutions. Am J Obstet Gynecol 1996;175:369–74.[Web of Science][Medline]
3. Thorp JA, Hu DH, Albin RM, et al. Reply [letter]. Am J Obstet Gynecol 1994;171:1401–10.
4. Johnson S, Rosenfeld JA. The effect of epidural anesthesia on the length of labor. J Fam Pract 1995;40:244–7.[Web of Science][Medline]
5. Lyon DS, Knuckles G, Whitaker E, Salgado S. The effect of instituting an elective labor epidural program on the operative delivery rate. Obstet Gynecol 1997;90:135–41.[Web of Science][Medline]
6. Gribble RK, Meier PR. Effect of epidural analgesia on the primary cesarean rate. Gynecol 1991;78:231–4.

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