Postponing epidurals won't reduce risk of C/S

Insisting that women in labor for the first time wait for epidurals does nothing to lower the cesarean section rate, according to a large, randomized, controlled trial in the New England Journal of Medicine.

The study included 750 nulliparous women at term whose cervices were dilated less than 4 cm. They were randomly assigned to receive either intrathecal fentanyl or an injection of hydromorphone the first time they asked for pain medication. At the second request for pain relief, the women who received spinals were given epidural analgesia and the women who received narcotics were given repeat narcotic injections. Once the women in the narcotics group reached a cervical dilatation of at least 4 cm, they were given an epidural, too.

There were no significant differences in C/S rates between the group that started with spinal analgesia and those started on systemic analgesia (17.8% vs. 20.7%; P=0.31). What was significant was that the women who started with intrathecal analgesia had a significantly shorter median time to complete dilatation (295 vs. 385 minutes; P<0.001), a shorter time to vaginal delivery (398 vs. 479 minutes; P<0.001), less pain (2 vs. 6 on a 0-to-10 scale; P<0.001), and fewer babies with 1-minute Apgar scores below 7 (16.7% vs. 24.0%; P=0.01). Five-minute scores, however, did not differ significantly between the two groups.

According to an editorial in the same issue of the Journal, nowhere else in medicine is it acceptable for a patient in pain and asking for relief to be denied medication. Adding insult to injury, systemic narcotics cross the placental barrier and often cause infant sedation. In addition, they frequently cause maternal sedation and nausea and interfere with a woman being able to participate actively in the birth of her child.

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.

Camann W. Pain relief during labor. N Engl J Med. 2005;352:718-720.