Health news - Early epidurals aren't caesarean risk
23 February 2005 - written by Bupa's Health information team
What did the study find?
New research from America suggests that having epidural pain relief early on in childbirth may not increase the risk of caesarean delivery.1,2
The study, published in the 17th February 2005 edition of the New England Journal of Medicine, also suggested that women who have early epidurals have shorter labour, less pain and gave birth to slightly healthier babies.1,2
What is an epidural?
The phrase "epidural" is used to describe a painkilling injection where the drug is delivered into a small space in the spine just below the spinal cord.3 It is a safe and reliable way of relieving pain from accidents and during operations.3
The painkilling drug (known as an anaesthetic) stops the nerves in the spinal cord carrying messages of pain from the lower half of the body to the brain. This results in a loss of feeling in the feet, legs, pelvis and stomach.3
For more information on epidural anaesthesia, please see our Bupa factsheet.
Factsheet: Epidurals for surgery and pain relief
Why do women have an epidural during labour?
An epidural removes feeling from the lower half of the body, so it can be used to remove the pains of childbirth without stopping the woman from feeling her baby being born.3
The decision to have an epidural always rests with the woman, but there are times when the doctor or midwife may recommend an epidural:3
- the labour is particularly long or painful
- it is possible that an operation (such as a caesarean delivery) may be needed
- you are having more than one baby (eg twins or triplets)
What are the benefits of having an epidural when giving birth?
Using epidural pain relief means that the lower doses of painkilling drugs are needed. In comparison with general anaesthesia, this means that there is:3
- less likelihood of side-effects
- faster recovery from the anaesthesia
Because of these factors, an epidural allows mothers to see and hold their babies straightaway and allows them to start breastfeeding sooner than with general anaesthesia.3
Another benefit of an epidural is that it actually helps the baby to move down the vagina more easily. This is because the drugs help the pelvic muscles to relax and the cervix to open wider.3
What are the disadvantages of having an epidural when giving birth?
Epidurals are both safe and reliable, however there are some problems that may occur during childbirth:3
- contractions during labour may not feel as strong, so the midwife may need to tell the woman when to push
- some women find their pelvic muscles become paralysed and they are unable to give birth without help from a doctor, using either forceps or suction
Sometimes these problems mean the baby needs to be delivered by caesarean.
What is a caesarean?
A caesarean or caesarean section involves the baby being surgically delivered through the abdominal wall.5 The surgeon usually makes a horizontal cut along the bikini line through the abdominal wall and then through the wall of the womb.5
Each year, 21 percent of all births in the UK are by caesarean.4
Why are some babies delivered by caesarean?
There are a number of reasons why a caesarean may become necessary during labour, for example if:5
- the baby is too delicate to be born normally (for example he or she is very small or is in distress)
- the mother has a condition that would put her at risk during childbirth
- the labour is not progressing as it should
- the mother's blood pressure becomes abnormally high (known as pre-eclampsia)
- the baby is unable to leave the womb, for example because the baby is too big, or is in the wrong position eg breech (bottom first), or the placenta is in the way
What are the risks of having a caesarean?
As with all types of surgery, there are risks involved with having a caesarean. However, doctors will only recommend a caesarean when normal delivery would be even more dangerous to either the baby or mother.5
The main risks of caesarean include:5
- temporary breathing problems for the baby
- temporary bladder control problems for the mother
- infection of the cut in the stomach wall
- blood clots in the legs of the mother (deep vein thrombosis or DVT)
Why was it thought that early epidurals could raise the risk of caesarean section?
Previous studies into the effects of early epidural pain relief in childbirth have suggested that that they increase the risk of needing a caesarean delivery.6,7
How was the study done?
The researchers studied the effects of epidural pain relief on 750 women who were giving birth for the first time and who asked for pain relief. All the women were giving birth at full term (ie not early).
The women were split into two groups.1,2
Group 1 (earlier epidural) women had:
- spinal pain relief (painkillers injected into the fluid surrounding the spinal cord, not the epidural space) the first time they asked for pain relief
- an epidural the second time they asked for pain relief, regardless of how much the cervix had opened
Group 2 (later epidural) women had:
- a standard pain relief injection the first time they asked for pain relief
- an epidural the third time they asked for pain relief or only after the woman's cervix had opened more than 4cm
What did the researchers measure?
The researchers looked at:1,2
- the rates of caesarean delivery
- the length of time it took for the cervix to fully open after pain relief had been started
- the length of time until delivery of the baby
- the women's assessment of pain on a scale of one to ten
- the fitness of the babies when they were born (using the one-minute Apgar test, which measures heart rate, respiration, muscle tone, reflux response and colour)
What did the researchers find?
The researchers found that:
- rates of caesarean delivery were similar for both groups of women
- length of time to the cervix being fully open was shorter with women who had an earlier epidural
- delivery of the baby was faster with earlier epidural pain relief
- women given early epidurals reported significantly lower pain
- the fitness of babies delivered to women with earlier epidurals was higher (fewer babies had Apgar scores of less than seven out of ten)
What does this mean?
These results suggest that early epidural pain relief during childbirth does not have an adverse effect. In fact they suggest that early use of an epidural may actually speed the labour and improve the baby's fitness at birth.
However, this study used a specialised type of epidural (where the first injection was into the fluid around the spinal cord), followed by standard epidural injections thereafter. This approach is not widely used in the UK.
The research also suggests that women do not need to worry that requesting an epidural early in their labour will adversely affect the labour or their baby's health.
Further information
Bupa resources:
External resources:
- Association of Anaesthetists
www.aagbi.org - American College of Obstetricians and Gynaecologists
www.acog.org - Royal College of Anaesthetists
www.rcoa.ac.uk - Royal College of Obstetricians and Gynaecologists
www.rcog.org.uk
References
- 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; 352:655-665.
http://content.nejm.org - Northwestern Memorial Hospital. Press release: Study finds no reason for expectant mothers to shy away from early Epidurals. 16/02/2005.
www.nmh.org - NHS Direct Online Health Encyclopaedia. Epidural anaesthesia.
www.nhsdirect.nhs.uk - Patient UK. Factsheet on Caesarean section.
www.patient.co.uk - NHS Direct Online Health Encylopaedia. Caesarean section.
www.nhsdirect.nhs.uk - Bandolier website. Review of evidence: Epidurals increase caesarean section rate. SC Morton, MS Williams, EB Keeler, JC Gambone, KL Kahn. Effect of epidural analgesia for labor on the Cesarean delivery rate. Obstetrics & Gynecology 1994 83: 1045-52.
www.jr2.ox.ac.uk/bandolier - Thorp JA, Hu DH, Albin RM et al. The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial. Am J Obstet Gynecol. 1993 Oct;169(4):851-8. Abstract accessed through PubMed.
www.ncbi.nlm.nih.gov/entrez/query.fcgi? - American College of Obstetricians and Gynaecologists. News release: ACOG Supports Epidural Pain Relief on Demand. 31/01/2002.
www.acog.org
All websites accessed on 18 February 2005
