title: Is the management of epidural analgesia associated with an increased risk of cesarean delivery?
abstract: OBJECTIVE
  The aim of this study was to quantify the association of cesarean delivery with epidural analgesia management, specifically with the timing of epidural catheter placement in relation to labor, the type of epidural analgesia, and the use of bolus dosing.
  
  
  METHODS
  A retrospective cohort design was used to investigate 1561 consecutive nulliparous parturients whose labor occurred between November 1, 1996, and June 30, 1997, at Northwestern Memorial Hospital and who were delivered of term, singleton neonates in a cephalic presentation. The relationship between the management of epidural analgesia and the risk for cesarean delivery was determined with stepwise logistic regression to control for potential confounding variables.
  
  
  RESULTS
  There was a significantly increased risk of cesarean delivery associated with decrements in cervical effacement (P =.001), cervical dilatation (P =.001), and fetal station (P =.001) at the time of epidural catheter placement. An increasing number of epidural boluses during the first stage of labor was also associated with increased risk of cesarean delivery (P =.001). After we controlled for maternal age, maternal body mass index, gestational age, infant birth weight, induction of labor, use of magnesium sulfate, and presence of chorioamnionitis, the adjusted odds of cesarean delivery associated with fetal station (odds ratio, 1.45; 95% confidence interval, 1.2-1.7) and epidural boluses (odds ratio, 1.55; 95% confidence interval, 1.3-1.8) during the first stage of labor remained significant.
  
  
  CONCLUSIONS
  The management of epidural analgesia during labor was associated with the potential for increased risk of cesarean delivery. This risk increased with higher stations of the fetal head at the time of epidural catheter placement and with more frequent epidural boluses of local anesthetic during the first stage of labor.
authors.affiliation: Department of Obstetrics and Gynecology, and the Department of Anesthesiology, Northwestern University Medical School and Northwestern Memorial Hospital, Chicago, IL, USA.
authors.forename: J D
authors.initials: JD
authors.lastname: Traynor
authors.forename: S L
authors.initials: SL
authors.lastname: Dooley
authors.forename: S
authors.initials: S
authors.lastname: Seyb
authors.forename: C A
authors.initials: CA
authors.lastname: Wong
authors.forename: A
authors.initials: A
authors.lastname: Shadron
mesh_terms: D015360:Analgesia, Epidural / Q000009:adverse effects* / Q000379:methods*; D001724:Birth Weight; D015992:Body Mass Index; D002585:Cesarean Section; D002821:Chorioamnionitis / Q000150:complications; D015331:Cohort Studies; D005260:Female; D005865:Gestational Age; D006801:Humans; D007751:Labor, Induced; D008278:Magnesium Sulfate / Q000627:therapeutic use; D008423:Maternal Age; D016017:Odds Ratio; D011247:Pregnancy; D012189:Retrospective Studies; D012307:Risk Factors
chemical_list: D008278:Magnesium Sulfate