Comparative Effectiveness of Interventions to Decrease Cesarean Births

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The AHRQ (Agency for Health Research and Quality), a section of the Department of Health and Human Services, has proposed a research topic entitled "Comparative Effectiveness of Interventions to Decrease Cesarean Births". The ASA and the Committee on Obstetric Anesthesia, in response to the call for comments, submitted the following comment to preemptively address misconceptions, still widespread in many circles, that neuraxial labor anesthesia contributes significantly to cesarean delivery rates.

The following comment is intended to address only one aspect of the care of the pregnant patient, pain management. The American Society of Anesthesiologists seeks to ensure that others' recommendations do not have the unintended consequence of preventing laboring women from receiving the most effective treatment of their pain.

Neuraxial Analgesia and Risk of Cesarean Delivery
Prepared on behalf of the American Society of Anesthesiologists Committee on Obstetrical Anesthesia by:
Cynthia A. Wong, M.D.
Professor of Anesthesiology
Northwestern University Feinberg School of Medicine
Chicago, IL 60611

In the past it was thought that neuraxial (epidural or spinal) analgesia caused an increase in the rate of cesarean delivery. Observational studies found that women who requested epidural analgesia had a higher cesarean delivery rate than women who received systemic opioid analgesia, or no analgesia. However, in the past several decades a number of randomized controlled trials in nulliparous women have shown that women randomized to receive neuraxial vs. systemic opioid analgesia do not have a higher cesarean delivery rate.1 Additionally, impact studies that compared the cesarean delivery rate before and after the introduction of epidural labor analgesia to individual institutions have shown that the cesarean delivery rates do not differ in the before- and after-periods, despite large increases in the proportion of women who received epidural analgesia.2,3 Similarly, observational studies found that women who asked for epidural analgesia early in labor had a higher cesarean delivery rate compared to women who asked for analgesia later in labor. However, randomized controlled trials of early vs. late initiation of neuraxial analgesia have found that the timing of initiation of analgesia does not influence the mode of delivery.4,5 The observation of higher cesarean delivery rates in women who request epidural analgesia is likely explained by the fact that women who have more pain during labor, and therefore request analgesia at a higher rate, have independent risk factors for operative delivery, such as dysfunctional labor or macrosomia.6,7 In a revised Committee Opinion published in 2006 the American College of Obstetricians and Gynecologists (ACOG) stated that, “fear of unnecessary cesarean delivery should not influence the method of pain relief that women can choose during labor.8

One factor contributing to the current high cesarean delivery rate is the practice of repeat elective cesarean delivery after an initial cesarean delivery. Many women are reluctant to undergo a trial of labor after cesarean (TOLAC) because of fear of prolonged and painful labor. At one time it was thought that epidural analgesia during TOLAC could mask the symptoms of uterine rupture, including pain; however, this is not been found to be the case.9 The ACOG has concluded that “adequate pain relief may encourage more women to choose TOLAC.”10

  1. Halpern SH, Leighton BL. Epidural analgesia and the progress of labor. In: Halpern SH, Douglas MJ, eds. Evidence-based Obstetric Anesthesia Oxford, UK: Blackwell, 2005:10-22
  2. Zhang J, Yancey MK, Klebanoff MA, Schwarz J, Schweitzer D. Does epidural analgesia prolong labor and increase risk of cesarean delivery? A natural experiment. Am J Obstet Gynecol 2001;185:128-34
  3. Segal S, Su M, Gilbert P. The effect of a rapid change in availability of epidural analgesia on the cesarean delivery rate: a meta-analysis. Am J Obstet Gynecol 2000;183:974-8
  4. Wong CA, Scavone BM, Peaceman AM, McCarthy RJ, Sullivan JT, Diaz NT, Yaghmour E, Marcus RJ, Sherwani SS, Sproviero MT, Yilmaz M, Patel R, Robles C, Grouper S. The risk of cesarean delivery with neuraxial analgesia given early versus late in labor. N Engl J Med 2005;352:655-65
  5. Wang F, Shen X, Guo X, Peng Y, Gu X. Epidural analgesia in the latent phase of labor and the risk of cesarean delivery: a five-year randomized controlled trial. Anesthesiology 2009;111:871-80
  6. Hess PE, Pratt SD, Soni AK, Sarna MC, Oriol NE. An association between severe labor pain and cesarean delivery. Anesth Analg 2000;90:881-6
  7. Alexander JM, Sharma SK, McIntire DD, Wiley J, Leveno KJ. Intensity of labor pain and cesarean delivery. Anesthesia & Analgesia 2001;92:1524-8
  8. ACOG committee opinion. No. 339: Analgesia and cesarean delivery rates. Obstet Gynecol 2006;107:1487-8
  9. Kieser KE, Baskett TF. A 10-year population-based study of uterine rupture. Obstet Gynecol 2002;100:749-53
  10. ACOG Practice bulletin no. 115: Vaginal birth after previous cesarean delivery. Obstet Gynecol 2010;116:450-63