Does early epidural increase risk of Caesarean section?

[Kosenrufugirl]

About 1 in 3 women in the UK get induced. Induction of labour often involves a hormonal drip.

I am a labour ward midwife.

I have noticed that women who have epidural sited before going on the hormonal drip seem to have an increased risk of an emergency Caesarean section compared to women who start the hormonal drip without epidural (some women in the 2nd group deliver without epidural, some will have an epidural later on in labour – the women in the 2nd group still seem to have less risk of an emergency Caesarean section).

I am considering applying for funding to do a piece of research. Do you think this topic: Does an early epidural increase risk of an emergency Caesarean section is worth doing research on?

All opinions would be much appreciated.

there's already a lot of published research on this subject. It may be worth chatting to the anaesthetists on your labour ward.

Thank you for your reply. I have already done a service evaluation for our entire maternity for the entire year for our Consultant anaesthetist (and presented my findings to the doctors).

I am aware of the line of thinking that an epidural is often the result of a labour that was bound to end up in a Caesarean section anyway (for example because of a malpositioned baby or baby too big for maternal pelvis).

However, when I looked at the studies, the vast majority were for low-risk women in spontaneous labour 3-5 cm dilated by the time they got an epidural.

On our labour ward, the women routinely get an epidural before going on the hormonal drip.

I am aware of the research that early epidural does not increase the risk of a CS. However, again, most studies are for low risk women in spontaneous labour.

Only 2 studies are for women on the induction pathway and in those 2 studies the women were already on the hormonal drip by the time they got an epidural.

There is only 1 study (Dickinson et al 2002) which investigated the effect of epidural on the risk an emergency CS in relation of wheter epidural was sited before or after the hormonal drip was commenced.

Hence I would like to do another study. However, I would like to know whether this topic would be an interest to women who already had a baby or might have a baby in the future

I chose a planned CS after evaluating the risk of my circumstances turning into an emergency CS after induction. So yes I think that this would be worthwhile research if the information is not already known.

Thank you so much your opinion and for taking the time to reply, much appreciated

I agree that if the studies have not yet been done this would be a worthwhile one for people who are due to be induced. I wasn't aware of this and I'm looking at induction for this baby and had considered whether I'd get the epidural before having the drip..if the evidence was available that it would increase the chance of CS then that would change my decision!

Many thanks for getting back to me!

Hello, while I was looking into childbirth options for my own pregnancy, I had understood that induction = more likely to want/need epidural = more likely to have a section, but admit I got this second hand from online sources (probably Sara Wickham, Rachel Reed etc).

My birth preferences were initially for an unmedicated birth. As I went "post dates" and was struggling to put off booking induction for any longer, I did discuss with my midwives having an epidural put in early (or maybe just the line for it... is that even possible?) Not actually clear on details as didn't get there in the end so didn't have to decide specifics: thankfully went into spontaneous labour a few hours before I was due to go in for induction.

I might have reconsidered my openness to an early epidural if I knew about research indicating that this correlates to increased chance of c section. Might've just gone straight to a section, actually.

Long story short: as a lay person, I think it would be a fascinating and very worthwhile research topic.

Sorry about multiple messaging: I'd definitely like to know this information for future pregnancies (if I have any). And also just to add in to the general picture

Thank you so much for the time to write to me and for your opinion. Congratulations on the birth of your baby!

This is exactly why I would like to do the research, thank you for posting

it's such a specific question it would need to be a pretty meaty piece of work involving large numbers of patients to demonstrate any sort of causative relationship rather than a correlation and to account for all the confounders that affect outcomes of inductions as women having inductions are such a heterogenous group (that doesn't mean it shouldn't necessarily be done, but just that this would likely be a big project). If the anaesthetists you work with have seen your data do they think this is a project with legs?... anaesthetists are generally a pretty risk averse bunch so if there were evidence that epidurals were causing adverse outcomes then we'd want to know, but I suspect if they've not suggested taking it forward (and internationally no one's thought of doing the same) then it may just be that your figures are a bit of a blip. Part of the problem with research that's attempted to explore possible adverse effects of epidurals is that a lot of it is small scale stuff of not great quality and that makes it fairly unhelpful so if you are going to take this forward it really needs to be a well thought through piece of work.

There was also a thread recently where someone asked the same question.

Thank you for your post and good advice. I am planning to do a cohort study for a very specific group of women on the induction of labour pathway- first-time mums with prolonged rupture of members who are not contracting and need to be induced with the hormonal drip. I agree with what you are saying in terms of confounders hence my very targeted group of women. I am on friendly terms with a lot of anaesthetists, they follow my ideas with interest. I am also well supported by the in-house research team. I should be able to pull this project off with their input as I am not going to test any new medicines or change a protocol. All I am planning is a retrospective analysis of 600 labour records. Hopefully my findings will reach statistical significance. I am applying for funding and part of my application process is finding out whether my topic is of interest to women- hence my post on Mumsnet. The last UK based RCT on the effect of epidural on the risk of an emergency CS is Howell etc al 2001 and it involved low-risk women on spontaneous labour. I would love to carry out an RCT on induced labour in the future but I need to start small. Thank you so much again for your interest in my topic and very valid points

Thank you, I will look it up

I do think it would be of interest as in both my pregnancies I thought a lot about epidurals. I went into my first thinking epidural will make interventions and c section more likely. I had the epidural after the hormone drip and gave birth vaginally, so fit your statistics. Second birth, I decided my threshold would be lower for asking for an epidural, but i didn't need it as it was quick.

However, first birth when I nearly had forceps I feel scared and guilty for getting an epidural. That fear did help me push baby out. The downside of research could be more guilt associated with a mother getting a c section she felt she could have prevented. Also, would timing be tricky, to get the anethatist in time.

Overall I do think more research is good. The c section rate is so high (more than 40% in my trust) so research into this would be good.

In the morning before my first birth, when I went into the labour ward, one of the first things the midwife said was I should be nill by mouth in case I needed a c section. I had prom, but overnight had dilated to 3cm. 5pm I had the drip, then at handover I had the epidural. 3am I gave birth. I hadn't seriously considered a c section before that point but during labour I would have loved to have been offered one.

I've read your other post. As a. Point of interest for you my mum had ruptured membranes and no contractions for all her births. First time they did the oxytocin drip and it did end in a c section, and was premature, I think 35 weeks. The next 3 were vbac but also need oxytocin as she had no contractions. This was in Holland with no epidurals.

I've had 3 inductions on the drip and just used gas and air every time. My last birth no one recognised I was at pushing stage despite me telling them. And I ended up with the epidural in for 8 minutes as they told me I had hours to go before pushing stage. To then deliver the baby as soon as the line was inserted. Feel really cheated tbh I done that well only to get it put in and I didn't even need it. I felt like the epidural was pushed on me from the first mention of me going on the drip.

Thank you so much for your reply. What you are saying about guilt fits with my observations- lots of mums feel guilty about getting an epidural. However some women are absolutely have their heart set at avoiding an emergency CS at all costs if at all possible. My rationale for doing this piece of research is to provide women with data to make an informed choice. In my unit, it's quite unusual for women to go on the hormonal drip without epidural. Even though in my professional experience a lot of mums o the hormonal drip cope brilliantly and some deliver without epidural. I think it's all about the informed choice really. Especially since we have a brilliant anaesthetic team who can usually make a woman pain free within one hour of the epidural request being made.

I am sorry to hear you felt pressurised into accepting an epidural for your 3rd birth. You must be so proud of yourself that you gave birth to your first 2 children on just gas and air. If you could go back in time and imagine yourself considering your pain relief options for your first induced labour..... do you think it would be good for you to know whether an early epidural increases the risk of an emergency CS? Do you think it's worth me doing this research to help first-time mums decide on their pain relief strategy?

Yes, I agree, my trust was really good about choices. Informed choice would naturally make a women feel more guilty as she now has the responsibility but that doesn't make it a bad thing. Worse to be powerless and out of control.

The obstricians I only saw briefly, maybe this is why an epidural wasn't pushed. Midwives were trying to get hold of the Dr, as I kept asking if I could eat/have a glucose injection. When I whole group of drs came round they said, your not in labour (what!). We are going to give you an oxytocin drip to get things going and you can eat first, so have half an hour to do that. By that point contractions were already too strong to eat much. No mention of an epidural, just vague, what's your birth plan from the midwives. I think that the don't offer, wait to be asked for pain relief was a good practice.

@Kosenrufugirl thank you.
Yes I'd like to know. I've watched all the series of one born every minute too and I've noticed that a lot of mums end up with interventions after an epidural too. Especially forceps delivery. It's defo some thing to look at.

Thank you for your reply, much appreciated

@TeaPleaseX we know that there is an association between having an epidural and having an assisted delivery (ie. ventouse or forceps), but whether that is a causative relationship is not clear and difficult to pick out. The association is clearly stated in the info card many units use as part of the consent process (produced by the obstetric anaesthetists association) am sure most anaesthetists will happily discuss it too.

I knew that it did, that it can slow labour down... I believe it was covered in my antenatal classes, but I'm based in Ireland.

I was recommended an early epidural as someone with a high BMI that was going to be induced (GDM). I had to have an antenatal consultation with the anaesthetist because I am obese. He really pushed an early epidural and when I said I didn't want one because of the risks of further interventions, he told me that it's correlation rather than causation, that the epidural isn't what raises the risks but the reason for induction etc. The midwife I spoke to afterward disagreed! So it seems that there isn't medical consensus on this. My mam is a retired midwife, and her advice was similar. We are told be upright and mobile aids labour, to work with gravity, and you can't do that properly after an epidural.

Anyway, I had an epidural when I was about 9cm and delivered without any further interventions. I don't know if my experience would have been the same if I'd had it earlier, but I'm happy with the choices I made.

I would be interested in your findings, especially if you include profiles of women with different risk factors.

I was in a drip for induction, got epidural way too early and never got past 5cm, had to have a c-section. My baby is 5 weeks old now and I'm fuming about how it all played out.