Epidural Analgesia and Cesarean Delivery

Abstract

In Response: We appreciate Dr. Tarshis' comments and interest in our report [1]. The primary reason we performed our study [1] was to test the inverse of Thorp's hypothesis [2,3], i.e., a large increase in labor epidural use would be associated with an increase in dystocia cesarean delivery. We successfully refuted this theory in a large, stable patient population with stable obstetric attending staff and policies. In fact, obstetric staff changes determined the start and end dates of our study. Among patients delivering before epidural analgesia was available, the dystocia (3.0%) and total (9.1%) cesarean delivery rates were quite low. In fact, these rates were among the lowest in Missouri at the time. It is not likely that changes in obstetric practice could have decreased these rates enough to counterbalance a cesarean-increasing effect of epidural analgesia. In addition, our results agree with those of Johnson and Rosenfeld [4], Lyon et al. [5], and Gribble and Meier [6]. It is highly unlikely that concurrent, unsuspected changes in obstetric practice coincided with large changes in epidural use in all four studies. As in many retrospective studies, there were undesirable deficiencies in our database. We were not able to separate patients in the after-group by both parity and epidural status. Because nulliparous patients have higher rates of both cesarean delivery and epidural use, not being able to separate After-Epidural and After-noEpidural patients by parity could have magnified the reported difference between these groups. Nonetheless, our results are similar to those of both Lyon et al. [5] and Gribble and Meier [6], who did separate patients by parity. We practice in an era in which third-party payor denials of epidural labor analgesia are justified as efforts to "save" women from cesarean delivery. Thus, we believe that it is important to compare our After-Epidural and After-noEpidural groups and to summarize the published and unpublished results of previous authors to emphasize that association does not prove causation. Women predestined to cesarean delivery request epidural analgesia much more frequently than women who deliver vaginally because dysfunctional labor hurts. Providing effective labor pain relief need not change a hospital's cesarean delivery rate. Steven T. Fogel, MD Department of Anesthesiology; Washington University School of Medicine; St. Louis, MO 63110-1093 Barbara L. Leighton, MD Department of Anesthesiology; Allegheny University Hospital for Women; Philadelphia, PA 19131-1696