The relationship between epidural analgesia and cesarean delivery remains controversial. Several studies have documented an association, although others have not. This inconsistency may result from an association between severe labor pain and dystocia. We hypothesized that dystocia causes severe labor pain, such that more epidural medication is required to maintain comfort. We examined the relationship between labor outcome and severe pain, defined by the number of supplemental epidural boluses. We retrospectively reviewed the anesthesia records of 4493 parturients who received small-dose labor epidural analgesia. An independent association was found between operative delivery and maternal age, body mass index, nulliparity, fetal weight, induction of labor, and the number of boluses required during labor. By using multivariate analysis, the odds ratio of cesarean delivery among women who required at least three boluses was 2.3 compared with those who required two boluses or less. No association was found between the concentration of bupivacaine in the epidural infusion and operative delivery. Because women with cesarean deliveries appeared to have more pain, degree of labor pain may be a confounding factor in studies examining epidural analgesia and outcome. Implications: This is a retrospective observational study demonstrating an association between labor pain and cesarean delivery. Our results provide an alternative explanation of why epidural analgesia is associated with cesarean delivery.
"Patients with a complicated labor may independently have a higher incidence of Cesarean section and instrumental delivery. In fact, Hess et al.  addressed this issue by investigating the association between severe labor pain and rates of Cesarean section. Patients who experienced three or more episodes of breakthrough pain during low-dose epidural bupivacaine/fentanyl labor analgesia had higher rates of Cesarean section in comparison to patients who experienced less pain (odds ratio 2.6, 95% CI 2.0 to 3.4). "
[Show abstract][Hide abstract] ABSTRACT: Labor pain is one of the most challenging experiences encountered by females during their lives. Neuraxial analgesia is the mainstay analgesic for intrapartum pain relief. However, despite the increasing use and undeniable advantages of neuraxial analgesia for labor, there have been concerns regarding undesirable effects on the progression of labor and outcomes. Recent evidence indicates that neuraxial analgesia does not increase the rate of Cesarean sections, although it may be associated with a prolonged second stage of labor and an increased rate of instrumental vaginal delivery. Even when neuraxial analgesia is administered early in the course of labor, it is not associated with an increased rate of Cesarean section or instrumental vaginal delivery, nor does it prolong the labor duration. These data may help physicians correct misconceptions regarding the adverse effects of neuraxial analgesia on labor outcome, as well as encourage the administration of neuraxial analgesia in response to requests for pain relief.
Korean journal of anesthesiology 11/2013; 65(5):379-384. DOI:10.4097/kjae.2013.65.5.379
"First, induced labor is often more painful than spontaneous labor. This increase in pain is indicated by the increase in epidural dosage among women with induced labor . Secondly, labor is induced more often when there are complications, and complications themselves are associated with epidural use . "
[Show abstract][Hide abstract] ABSTRACT: Identify variables associated with intrapartum epidural use.
Odds ratios were calculated to quantify associations between selected variables and epidural use using a population-based case-control study of Washington State birth certificate data from 2009.
Non-Whites had 10 - 45% lower odds of epidural use relative to Whites. Foreign-born women had 25 - 45% lower odds of epidural use compared to their US-born counterparts, except for Asians. Women who smoked or induced labor had higher roughly 2-fold higher odds of epidural use compared with non-smokers or women giving birth spontaneously, respectively. Women without a high school diploma or equivalent had lower odds of epidural use relative to those who graduated. Delivering at perinatal units, rural hospitals, or non-profit hospitals had ~50% lower odds of epidural use compared with secondary/teritiary perinatal units, urban hospitals or for-profit hospitals, respectively.
Several individual and health service-related variables were associated with epidural use. These findings elucidate the clinical relevance of epidural use, and dispariaties in its utilization and in quality of care during delivery.
Epidural use; Foreign birth; Labor; Racial disparities.
Journal of Clinical Medicine Research 04/2012; 4(2):119-26. DOI:10.4021/jocmr810w
"Il faut également souligner le caractère subjectif de nombreux critères d'évaluation comme la dilatation ou la souplesse du col, ce qui favorise l'introduction de biais de mesure. D'autres difficultés méthodologiques sont représentées par l'absence d'homogénéité des conduites obstétricales , des types de populations et par l'indication même de l'analgésie, car la douleur  peut représenter un biais d'auto-sélection des cas difficiles et dystociques . De manière corollaire, le recours à une perfusion ocytocique, voire à une extraction instrumentale, est plus facile lorsque l'obstétricien sait que la parturiente bénéficie d'une analgésie confortable et d'un relâchement pelvien de qualité  (NP4). "
[Show abstract][Hide abstract] ABSTRACT: The aim of the anaesthesia for instrumental delivery is to provide optimal operation conditions for the obstetrician, appropriate maternal comfort, altogether with safety for the mother and her fœtus. The type and location for this intervention are chosen individually for each case according to the indication, the risk of caesarean section and the local specificities. The general safety recommendations for obstetric anaesthesia apply in every case. Since an epidural analgesia is often already working, this type of anaesthesia is the most frequently used for the extractions. A spinal anaesthesia is a logical choice where an epidural in sot yet working. The pudendal block is a second line choice and the general anaesthesia remains as the last alternative in acute emergencies, in cases of failed regional anaesthesia or when the mother refuses any other anaesthesia despite proper information or proves unable to cooperate.
Journal de Gynécologie Obstétrique et Biologie de la Reproduction 12/2008; 37(8). DOI:10.1016/S0368-2315(08)74764-1 · 0.56 Impact Factor
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