ACOG Committee Opinion
Number 339, June 2006
(Reaffirmed 2013, Replaces No. 269, February 2002)


Committee on Obstetric Practice

This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. 


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Analgesia and Cesarean Delivery Rates

ABSTRACT: Neuraxial analgesia techniques are the most effective and least depressant treatments for labor pain. The American College of Obstetricians and Gynecologists previously recommended that practitioners delay initiating epidural analgesia in nulliparous women until the cervical dilatation reached 4–5 cm. However, more recent studies have shown that epidural analgesia does not increase the risks of cesarean delivery. The choice of analgesic technique, agent, and dosage is based on many factors, including patient preference, medical status, and contraindications. The fear of unnecessary cesarean delivery should not influence the method of pain relief that women can choose during labor.

Neuraxial analgesia techniques (epidural, spinal, and combined spinal–epidural) are the most effective and least depressant treatments for labor pain (1, 2). Early studies generated concern that the benefits of neuraxial analgesia may be offset by an associated increase in the risk of cesarean delivery (3,4). Recent studies, however, have determined that when compared with intravenous systemic opioid analgesia, the initiation of early neuraxial analgesia does not increase the risk of cesarean delivery (5–7).

In 2000, the American College of Obstetricians and Gynecologists (ACOG) Task Force on Cesarean Delivery recommended that "when feasible, obstetric practitioners should delay the administration of epidural anesthesia in nulliparous women until the cervical dilatation reaches at least 4–5 cm" (8). This recommendation was based on earlier studies, which suggested that epidural analgesia increased the risk of cesarean delivery by as much as 12-fold (3, 4, 9, 10). Furthermore, certain studies demonstrated an even greater association between epidural analgesia and cesarean delivery in women who received their epidurals before reaching cervical dilatation of 5 cm (3, 9). In 2002, an evaluation of cesarean delivery sponsored by ACOG concluded, "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 of cesarean delivery (8).

Since the last Committee Opinion on analgesia and cesarean delivery, additional studies have addressed the issue of neuraxial analgesia and its association with cesarean delivery. Three recent meta-analyses systematically and independently reviewed the previous literature, and all concluded that epidural analgesia does not increase the rates of cesarean delivery (odds ratio 1.00–1.04; 95% confidence interval, 0.71–1.48) (11–13). In addition, three recent randomized controlled trials clearly demonstrated no difference in rate of cesarean deliveries between women who had received epidurals and women who had received only intravenous analgesia (5–7). Furthermore, a randomized trial comparing epidurals done early in labor versus epidurals done later in labor demonstrated no difference in the incidence of cesarean delivery (17.8% versus 20.7%) (5). The use of intrathecal analgesia and the concentration of the local anesthetic used in an epidural also have no impact on the rate of cesarean delivery (5, 13–15).

Therefore, ACOG reaffirms the opinion it published jointly with the American Society of Anesthesiologists, in which the following statement was articulated: "Labor causes severe pain for many women. There is no other circumstance where it is considered acceptable for an individual to experience untreated severe pain, amenable to safe intervention, while under a physician's care. In the absence of a medical contraindication, maternal request is a sufficient medical indication for pain relief during labor" (16). The fear of unnecessary cesarean delivery should not influence the method of pain relief that women can choose during labor.

The American College of Obstetricians and Gynecologists recognizes that many techniques are available for analgesia in laboring patients. None of the techniques appears to be associated with an increased risk of cesarean delivery. The choice of technique, agent, and dosage is based on many factors, including patient preference, medical status, and contraindications. Decisions regarding analgesia should be closely coordinated among the obstetrician, the anesthesiologist, the patient, and skilled support personnel.

References

  1. Gibbs CP, Krischer J, Peckham BM, Sharp H, Kirschbaum TH. Obstetric anesthesia: a national survey. Anesthesiology 1986;65:298–306.
  2. Hawkins JL, Gibbs CP, Orleans M, Martin-Salvaj G, Beaty B. Obstetric anesthesia work force survey, 1981 versus 1992. Anesthesiology 1997;87:135–43.
  3. Thorp JA, Hu DH, Albin RM, McNitt J, Meyer BA, Cohen GR, et al. The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial. Am J Obstet Gynecol 1993;169:851–8.
  4. Ramin SM, Gambling DR, Lucas MJ, Sharma SK, Sidawi JE, Leveno KJ. Randomized trial of epidural versus intravenous analgesia during labor. Obstet Gynecol 1995;86:783–9.
  5. Wong CA, Scavone BM, Peaceman AM, McCarthy RJ, Sullivan JT, Diaz NT, et al. The risk of cesarean delivery with neuraxial analgesia given early versus late in labor. N Engl J Med. 2005;352:655–65.
  6. Sharma SK, Alexander JM, Messick G, Bloom SL, McIntire DD, Wiley J, et al. Cesarean delivery: a randomized trial of epidural analgesia versus intravenous meperidine analgesia during labor in nulliparous women. Anesthesiology 2002;96:546–51.
  7. Halpern SH, Muir H, Breen TW, Campbell DC, Barrett J, Liston R, et al. A multicenter randomized controlled trial comparing patient-controlled epidural with intravenous analgesia for pain relief in labor. Anesth Analg 2004; 99:1532–8.
  8. American College of Obstetricians and Gynecologists. Evaluation of cesarean delivery. Washington, DC: ACOG; 2000.
  9. Lieberman E, Lang JM, Cohen A, D'Agostino R Jr, Datta S, Frigoletto FD Jr. Association of epidural analgesia with cesarean delivery in nulliparas. Obstet Gynecol 1996; 88:993–1000.
  10. Howell C, Chalmers I. A review of prospectively controlled comparisons of epidural with non-epidural forms of pain relief during labour. Int J Obstet Anesth 1992;1:93–110.
  11. Leighton BL, Halpern SH. The effects of epidural analgesia on labor, maternal, and neonatal outcomes: a systemic review. Am J Obstet Gynecol 2002;186:S69–77.
  12. Liu EH, Sia AT. Rates of caesarean section and instrumental vaginal delivery in nulliparous women after low concentration epidural infusion or opiod analgesia: systemic review. BMJ 2004;328:1410.
  13. Sharma SK, McIntire DD, Wiley J, Leveno KJ. Labor analgesia and cesarean delivery: an individual patient meta-analysis of nulliparous women. Anesthesiology 2004;100:142–8.
  14. Effect of low-dose mobile versus traditional epidural techniques on mode of delivery: a randomised controlled trial. Comparative Obstetric Mobile Epidural Trial (COMET) Study Group UK. Lancet 2001;358:19–23.
  15. Chestnut DH, McGrath JM, Vincent RD Jr, Penning DH, Choi WW, Bates JN, et al. Does early administration of epidural analgesia affect obstetric outcome in nulliparous women who are in spontaneous labor? Anesthesiology 1994;80:1201–8.
  16. Pain relief during labor. ACOG Committee Opinion No. 295. American College of Obstetricians and Gynecologists. Obstet Gynecol 2004;104:213.

This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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Analgesia and cesarean delivery rates. ACOG Committee Opinion No. 339. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;107:1487–8.