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.

Surely France would have a lot of data on this, if it is true they treat epidural as standard?

One thing I would be wary of - plenty of women report not being able to get an epidural in time/at all, and there is little else in way of decent pain relief for labour. If your research does indeed support your theory, will it be used as a way of removing pain relief from women? From a purely financial perspective, reducing epidurals and CSs would save costs (up front), but will that be at the detriment of women in terms ofmpatient care? No one should have to "cope" unless they are really clear that they do not want pain relief.

It probably wouldn't reduce the number of sections though would it because a significant number of women would decline to start an induction and would just go on to have a section anyway. You're right though - there aren't many good alternatives to epidurals in terms of pain relief - remifentanil is probably the best but isn't without problems of it's own, isn't currently universally available and may not be the best option for women living with obesity. Entonox and IM opioids are a bit like marmite to women (and entonox is probably on the way out now due to environmental and wider medical concerns). That leaves us with having a bash on synto without pain relief or declining the induction and having a cat 3/4 section. Also, from anecdata, one of the determinents of how long it takes to provide an epidural is when the midwife actually tells the anaesthetist about the request....which isn't always at the same time that the woman actually requests it.

The French population may not be that easy to compare with the UK population.

Thank you for your reply. I am so happy to hear you had a good experience. I would love to be able to do a study to compare labour outcomes in relation to epidural timing for women with BMI over 35. However, in order to make the findings credible, the researcher needs to be very careful with which groups to study. To establish the link (if it exists) it's helpful to compare like for like. I have a personal experience of prolonged rupture of membranes, which is partly the reason I chose this group of women. My fellow research midwife is interested in labour outcomes for women with raised BMI. You have a very valid point, I will pass your suggestion over to her

I am really sorry you feel cheated of a good birth experience you were hoping to have. Please do bear in mind that some labours will end up in an emergency Caesarean regardless whether a woman has an epidural or not. Some babies end up in a silly position and Caesarean section is sometimes the only safe option to deliver the baby. If you are ever brave enough to have another child, you might want to consider VBAC (vaginal birth after Caesarean). You would need to be counselled on the risks. However you got to 5 cm, it's really encouraging. My top tips would be to wait for at least 18 months before getting pregnant, make sure your BMI is 25 or less before trying for a baby and don't eat for 2 in pregnancy. Going back to my research question... do you think it's a good idea for me to do my piece of research? My thinking is that if my study was to conclude that epidural before the hormonal drip increases the risk of an emergency CS some women might decide to hold off epidural for as long as possible. Or at least be in a position to decide what's most important to them: pain-free labour or reduced risk of an emergency CS. Do you think this study is worth undertaking?

Thank you for your reply, you are raising really important points. Since Ockenden report the Trusts are not allowed to pursue arbitrary CS rates targets. Also, being denied pain relief in labour is number one complaint on the labour ward. Which is why the epidural rate is probably too high in a lot of Trusts - midwives are too scared to explain to women the consequences of their epidural request- for example, women on epidural are much more likely to end with fever and need intravenous antibiotics in labour. Also, women in spontaneous labour are much more likely to end up needing a hormonal drip. Yes, epidural usually provides an amazing pain relief. However some women put more emphasis on natural delivery over pain-free delivery. What I am trying to achieve with my piece of research is enable women to make an informed choice.

I am finding it really sad that in some places the midwife doesn't notify the anaesthetist straight away once epidural request is being made. This is not the practice in our Trust. I am not convinced that women will refuse to be induced if they would know delaying epidural by a few hours would result in a lower chance of an emergency CS (if, of course, my clinical hunch is confirmed). An emergency CS will always be necessary to safely deliver some babies, whether it's an induced or spontaneous labour. I don't think my research will put women off having an induction. I am hoping it would make them consider what's most important to them - pain-free labour or maximum chance of a vaginal delivery (if my clinical hunch is confirmed)

Further to the earlier message- remifentanil is now in the NICE intrapartum guideline (September 2023). It's not an exotic drug. It's ought to be available everywhere to give women maximum choice. Some women really hate the idea of needing an epidural.

@Greybeardy

I am one of those women who would at least consider picking a c section over the hormone drip. For me personally, I'm not sure there's any benefit in having a highly medicated, unnatural, vaginal birth (that might well end in forceps of an unplanned c section anyway). Nope, not for me. Spontaneous labour or bust! I may be in a minority though...

Hi OP, this would definitely make an interesting study. I agree with the points @Greybeardy made. In response to her post you wrote:

"All I am planning is a retrospective analysis of 600 labour records. Hopefully my findings will reach statistical significance."

My thoughts are that 600 is a relatively small sample size - definitely have a statistician do a power calculation for you to check that your study will be sufficiently powered to detect an effect if it exists (underpowered studies are frustrating as no firm conclusions can be drawn from them, and are not a good use of limited research funding).

Also as the researcher you should be neutral as to what the data will show and have your analyses planned a priori (i.e. not actively 'hoping'/fishing the data for a particular result. Also the term 'statistical significance' is outdated - instead the p-value should be interpreted as strength of evidence against the null hypothesis.

(Sorry I know you didn't ask for a research skills lesson but your research question sounds really interesting and valuable and I hope the study goes well. I look forward to reading the results 😊)

The possibility of this research being used to remove pain relief options crossed my mind as well - at first glance it comes across as a way to refuse women epidurals. I'll be honest and say that my main concern about being in labour was being refused pain relief (I wasn’t refused it, but it was a worry), and I know other people who felt the same way.

Anecdotal advice on MN is that if you are being induced with a drip, you should request an epidural first as it can be very painful. Is this something that has been studied in any way?

@EllieQ

This is tricky isn't it? I feel like knowledge/information is power... but only if it doesn't result in options being removed. But presumably a woman could refuse to be put on the drip without pain relief... (that said it is REALLY hard to be assertive in that kind of situation)

I loved gas and air and am afraid they will get rid of it, instead of finding a way to make it safer. I would be very afraid of going into labour without g&a available. So I totally get the fear.

I think this sounds like an interesting piece of research. I agree with the above posts about the possibility of this making it even harder for women to get an epidural.
From my own experience, I had to be really firm and insistent in order to get one - and this was from advice from friends who had also had to have the same approach. I did get one in the end and it was a godsend. I felt very pushed into going for a 'natural' birth when I had wanted an epidural from the start, and I don't think the trust I was under had a system of requesting an epidural from the anaesthetist straight away.

Thank you so much for your advice and your encouragement, I will definitely request another session with a statistician. I am aware a researcher should undertake any piece of research with an an open mind. I am however hoping that the sample of 600 women would be sufficient to either prove or disprove my hypothesis. If I was to carry out the study I would definitely publish the findings - that's the whole idea of doing the healthcare research- for patients' benefit

Thank you for your reply. I appreciate your concern about being denied pain relief in labour. As I have mentioned already this is number one complaint on our labour ward so every midwife strives to provide the best care and calls the anaesthetist promptly. Saying this, a couple of Mumsnetters on this thread complained they felt pressurised into taking an epidural. To me this is just as wrong as denying women an epidural when they want one. Yes there is plenty of research that women find induced labour more painful and are more likely to request an epidural. (Saying this, I have seen plenty of spontaneous labours that end up being obstructed - the pain could be excruciating). It has been my clinical experience that if epidural is sited at least 2 hours after the hormonal drip is commenced there's a noticeable decrease in the risk of an emergency CS. Some women on the hormonal drip in my care (a minority) decided that the pain isn't that bad after all and went on to deliver without epidural (often to their great surprise). What I am hoping to achieve with my research is to give women more information to base their decisions on. I am aware of this line of thinking: induced labour is painful, the woman is likely to ask for an epidural anyway, so why not start it before starting the hormonal drip. However if my research was to indicate doing so might increase the woman's risk of an EMCS this might affect woman's decisions on epidural timing. Do you think this piece of research is worth doing?

Thank you for your post. I am sorry to hear you had to fight to get your epidural. It shouldn't be this way. All choices should be respected- the choice of women wanting an epidural and the choice of women who decline it.