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~ Women Receiving Epidural Early in Labor No More Likely To Have C-Section Than Women Receiving Epidural Later, Study Says

Kaisernetwork.org Daily Reproductive Health Report ~ February 17, 2005

Women who receive epidural anesthesia early in labor are no more likely to undergo a caesarean-section delivery than women who receive systemic narcotics for initial pain and do not receive an epidural until later in labor, according to a study published in the Feb. 17 issue of the New England Journal of Medicine, the Boston Globe reports. Dr. Cynthia Wong, an obstetric anesthesiologist at Northwestern Memorial Hospital, and colleagues at Northwestern University studied 728 women laboring at Prentice Women's Hospital in Chicago between 2000 and 2003 (Johnson, Boston Globe, 2/17). All of the women were giving birth for the first time, and all requested pain medication during labor. The researchers then randomly assigned the women to receive one of two pain-relief methods. The first group received anesthesia injected into their spinal space at first request for pain medication and an anesthetic injection into their epidural space when their cervices were dilated about two inches. The second group received systemic narcotics upon first request for pain medication and did not receive an epidural until their third request for additional pain medication or their cervices had dilated at least four inches, whichever happened first.

Findings
Among women in the early epidural group, approximately 18% subsequently underwent c-section deliveries, compared with 21% in the delayed epidural group, a difference that was not statistically significant (Donn, AP/Long Island Newsday, 2/17). However, the median pain labor pain score as rated by women in the early epidural group was a two on a scale of one to 10, compared with a median score of six for women in the delayed epidural group. Also, infants born to women in the early epidural group were "more alert" upon delivery, according to the Chicago Sun-Times (Ritter, Chicago Sun-Times, 2/17). Although some health professionals have expressed concern that epidural provision slows down contractions and labor progress, the study found that the average time between epidural provision and full cervical dilation was about 295 minutes for the early epidural group, compared with 385 minutes for the delayed epidural group (BBC News, 2/17). In addition, women in the early epidural group on average had total labor times that were 90 minutes shorter than the labor times of women in the delayed epidural group (AP/Long Island Newsday, 2/17).

Researcher Conclusions
"The message of this is that there is no reason why women who want an epidural should not get it when they first request it," Wong said (Bowman, Scripps Howard/Knoxville News-Sentinel, 2/17). She added that women often are "pressured" to delay receiving an epidural and made to feel "guilty or weak" if they requested one too early in labor, according to the New York Times (Grady, New York Times, 2/17). "Doctors should feel comfortable they're not increasing the risk of their patient getting a c-section by allowing them to get an epidural earlier in labor," Wong said (Emery, Reuters, 2/16).

ACOG Recommendations
The new study's findings appear to "contradict" previous research that showed women who received early epidurals required more c-section deliveries than women who delayed receiving epidurals, according to the AP/Newsday (AP/Long Island Newsday, 2/17). The American College of Obstetricians and Gynecologists recommends delaying an epidural, when "feasible," until the cervix is dilated at least four centimeters, especially for women giving birth for the first time, the New York Times reports (New York Times, 2/17). In February 2002, ACOG issued an opinion statement -- following reports that some medical institutions have policies that restrict women from receiving epidurals until the cervix has dilated to a diameter of at least four to five centimeters -- to clarify its position. ACOG said that a woman who requests an epidural anesthetic to relieve labor pain should receive one regardless of her stage of labor. Contradictory evidence on whether or not receiving an epidural earlier in pregnancy put women at an increased risk for a c-section delivery prompted an ACOG task force in 2000 to examine the issue. The task force concluded that epidurals should be delayed when feasible, but its recommendation specifically stated that providers should not intentionally limit pain relief to women in labor (Kaiser Daily Reproductive Health Report, 2/4/02). ACOG officials said they are unlikely to change their guidelines in reaction to the study findings because the spinal-epidural combination used in the study is an "uncommon method" for receiving an epidural, according to the Globe. Approximately 60% of women who give birth in the United States receive an epidural during labor, according to the Globe (Boston Globe, 2/17).

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Reaction, Editorial
Dr. Laura Riley, director of labor and delivery at Massachusetts General Hospital in Boston, agreed with the ACOG officials, saying that the type of epidural studied by the Northwestern researchers is "very intricate," adding, "I don't know that many places that can do it." She also said the study's findings "may just pertain to this group of patients," adding, "It's not clear that this is really generalizable." In an accompanying NEJM editorial, Dr. William Camann, an anesthesiologist at Brigham and Women's Hospital in Boston, wrote that women were "forced to endure extra hours of pain for no reason and given narcotics that did not work well," according to the Times. "Women in labor deserve to have as many options as possible at their disposal to ensure a safe and satisfying birth experience both for themselves and for their infants," Camann writes (New York Times, 2/17). The study's findings "make it clear that safe, effective pain relief with the use of regional anesthetics should not be withheld simply because an arbitrary degree of cervical dilatation has not yet been achieved," Camann concludes (Camann, NEJM, 2/17).

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