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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