Epidural Analgesia and Risks of Cesarean and Operative Vaginal Deliveries in Nulliparous and Multiparous Women

Uyen-Sa D. T. Nguyen; Kenneth J. Rothman; Serkalem Demissie; Debra J. Jackson; Janet M. Lang; Jeffrey L. Ecker


Matern Child Health J. 2010;14(5):705-712. 

In This Article

Abstract and Introduction


Objective is to examine the effect of epidural analgesia in first stage of labor on occurrence of cesarean and operative vaginal deliveries in nulliparous women and multiparous women without a previous cesarean delivery. Design of the Prospective cohort study. Prenatal care was received at 12 free-standing health centers, 7 private physician offices, or 2 hospital-based clinics; babies were delivered at a free standing birth center or at 3 hospitals, all in San Diego, CA. This study of 2,052 women used data from the San Diego Birth Center Study that enrolled women between 1994 and 1996 to compare the birthing management of the collaborative Certified Nurse Midwife- Medical Doctor Model with that of the traditional Medical Doctor Model. Main Outcome Measures of the Cesarean or operative vaginal deliveries. After adjusting for differences between women who used and those who did not use epidural analgesia in 1st stage of labor, epidural use was associated with a 2.5 relative risk (95% CI: 1.8, 3.4) for operative vaginal delivery in nulliparous women, and a 5.9 relative risk (95% CI: 3.2, 11.1) in multiparous women. Epidural use was associated with a 2.4 relative risk (95% CI: 1.5, 3.7) for cesarean delivery in nulliparous women, and a 1.8 relative risk (95% CI: 0.6, 5.3) in multiparous women. Epidural anesthesia increases the risk for operative vaginal deliveries in both nulliparous and multiparous women, and increases risk for cesarean deliveries in nulliparous more so than in multiparous women.


Whether epidural use increases a woman's risk for a cesarean delivery is a question that has received much debate. The American College of Obstetricians and Gynecologists (ACOG) Committee stated in 2002 that ''there is considerable evidence suggesting that there is in fact an association between the use of epidural analgesia for pain relief during labor and the risk for cesarean delivery''.[1] It is thought that epidural analgesia causes dysfunctional labor, prolongs length of labor, relaxes pelvic floor muscle, reduces maternal urge to push; thus, increasing the likelihood of a cesarean delivery.[2]

In 2006, however, ACOG suggested that more recent studies offered no evidence that epidural analgesia increased the risk for cesarean delivery.[1] Several studies that swayed ACOG's change in opinion were those of Sharma et al.[3] and Wong et al.[4] Yet, approximately 20% of subjects from the Sharma's study did not comply with the assigned treatment group. Moreover, in Wong's study, the risk for cesarean delivery in the referent group was high, possibly because some women in this group also received epidural during labor. Lack of adherence to the randomized assignment coupled with intent-to-treat analysis rather than as-treated (per protocol), and trial designs that do not distinguish completely between epidural and no epidural anesthesia, may have biased the results of the previous randomized studies in the direction of underestimating an effect of epidural anesthesia on the risk for cesarean delivery.[5]

The purpose of the current research is to examine the effect of epidural placement on cesarean sections and operative births in a cohort of nulliparous women, and multiparous women without a previous cesarean delivery.


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