dear all

I haven't looked the the Cochrance review in a while, but from my
recollection, controlled studies of good quality that were excluded (as
not RCTs) did find an association, but the RCTs included did not find a
significant association with CS. They did with instrumental births,
though, and this should be sufficient to be able to advise caution, and
certainly to inform women of this. 

RCTs of something like epidural are very difficult to conduct
effectively, as the options cannot be blinded, recruitment can be
difficult, and crossover from  one option to another too high for the
results to be totally confident (ie. a certain number of people in the
intervention group will not use it, and a certain number in the control
group will use the intervention, thus decreasing the ability to compare
in a controlled way). I would suggest this is a good reason for being
prepared to look at other good controlled studies too.

I would recommend reading the Cochrane review - including the reviewers'
detailed commentary and tables.

Also, does the labour ward have evidence-based guidelines that apply to
all professional groups?

Chris


-----Original Message-----
From:	A forum for discussion on midwifery and reproductive health
research. on behalf of Michelle Kealy
Sent:	Mon 30-Apr-07 3:51 AM
To:	[log in to unmask]
Cc:	
Subject:	Re: link between epidurals and caesareans?

Message below forwarded on behalf of Mary-Ann Davey:

It would be worth looking carefully at the studies included in the
Cochrane review of this topic.  I know the review found no association
between epidurals and caesareans. However many observational studies
(including my own in-progress analysis for my doctoral thesis) do find
an association.  And that matches what many of us have noted in
practice.  So I'm not sure whether there are fatal flaws in some of the
studies in the Cochrane review. If not, it's pretty hard to argue with!
The Cochrane review did find a link with instrumental vaginal births
though.

All the best

Mary-Ann Davey 

-----Original Message-----
From: A forum for discussion on midwifery and reproductive health
research. [mailto:[log in to unmask]] On Behalf Of Jane
Sandall
Sent: Monday, 30 April 2007 3:09 AM
To: [log in to unmask]
Subject: link between epidurals and caesareans?

  I wonder if you could help me with a question I am grappling with on a
Labour Ward Forum.

 

Are you aware of any current research that shows a link between
epidurals and caesareans?

 

I sit on a NHS Labour Ward Forum, where there is a concerning trend to
direct women with a BMI greater than 35 directly to an anaesthetist, who
persuasively encourages them to have an epidural in early labour.  The
caesarean section rate is also approximately 26%, not all of which can
be ascribed to high BMI women!

 

I know there are risks with a high BMI, and epidurals are easier to site
in early labour, but I am very concerned on several counts.  Firstly it
rockets women in to a higher risk category that might not need to be
there.  Secondly there is no hint of informed decision making - the
anaesthetist is very directive and persuasive.  But my third and
greatest concern, and the one for which I would be grateful for your
help, is that the anaesthetist claims that there is categorically no
extra risk of a caesarean for these women as a result of the epidural.
At the last LWF, a junior doctor also claimed this for epidurals.

 

I have found several research papers that cite no extra risk - however I
can see flaws in the research.  

 

From my own practice as an NCT antenatal teacher and tutor I strongly
believe that there is a link.  I am aware of several pieces of research
linking epidurals and increased risk of caesarean.  

 

This is one of them:-

The effect of intrapartum epidural analgesia on nulliparous labor: a
randomized, controlled, prospective trial. Thorp JA, Hu DH, Albin RL, et
al. Am J Obstet Gynecol 1993;169(4):851-8.

OBJECTIVE: Our purpose was to determine the effect of epidural analgesia
on nulliparous labor and delivery. STUDY DESIGN: Normal term nulliparous
women in early spontaneous labor were randomized to receive either
narcotic or epidural analgesia. RESULTS: When compared with the group
receiving narcotic analgesia (n = 45), the group receiving epidural
analgesia (n = 48) had a significant prolongation in the first and
second stages of labor, an increased requirement for oxytocin
augmentation, and a significant slowing in the rate of cervical
dilatation. Epidural analgesia was associated with a significant
increase in malposition (4.4% vs 18.8%, p < 0.05). Cesarean delivery
occurred more frequently in the epidural group (2.2% vs 25%, p < 0.05),
primarily related to an increase in cesarean section for dystocia (2.2%
vs 16.7%, p < 0.05). CONCLUSIONS: In a randomized, controlled,
prospective trial epidural analgesia resulted in a significant
prolongation in the first and second stages of labor and a significant
increase in the frequency of cesarean delivery, primarily related to
dystocia. 

I have found another that links induction and epidural with caesarean
(Kaul et al (2004), and a BMJ 2004 piece that low dose epidurals don't
show a link with caesareans - however what's a 'low dose', and what are
the links to caesareans with 'high dose' epidurals?

 

I am concerned at tabling research from 1993.  I would be very grateful
for any other research or further detail you might have.  Conversely, if
I am wrong I more than happy to be set right.

 

Thank you for your help.

 

Pam

 

 

Pam Fenton

National Childbirth Trust - National Tutor

tel. 01494 718502

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