Receiving Epidural Analgesia During Labor May Reduce Serious Maternal Complications

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Women who received epidural analgesia during labor were less likely to experience severe maternal morbidity complications, such as heart attack or heart failure and sepsis.

Women in labor receiving epidural -- Image credit: Firma V | stock.adobe.com

Image credit: Firma V | stock.adobe.com

Receiving an epidural during labor is associated with a reduction in serious complications, known as severe maternal morbidity (SMM), in the first few weeks following birth, according to the results of a population-based cohort analysis in Scotland. The study was published in the British Medical Journal.1 These complications can include heart attack, heart failure, sepsis, and in some cases, hysterectomy.2

Epidural analgesia is usually recommended or medically indicated for women who have known risks for SMM (eg, obesity, underlying conditions, having more than 1 baby). Prior research suggested that epidural analgesia during labor may reduce the risk of SMM, but evidence was limited.1,2

For this study, the investigators enrolled a total of 567,216 women who were in labor at 24+0 to 42+6 weeks' gestation between January 1, 2007, and December 31, 2019, who were delivering either vaginally or through an unplanned caesarean section (C-section). The primary end point for the study was SMM as defined as the presence of 1 or more conditions—out of a possible 21—that are used by the CDC as criteria for SMM, or a critical care admission that occurs at any point from date of deliver to 42 days postpartum. In addition, secondary end points included both 1 or more of the 21 SMM conditions and critical care admission, as well as respiratory mortality.1

The findings show that out of the study population, 125,024 women (22%) had epidural analgesia during labor, with SMM occurring in 2412 women, approximately 4.3 women per 1000 births (95% CI 4.1-4.4). Additionally, the study demonstrates that epidural analgesia was associated with an approximate 35% reduction of SMM symptoms (adjusted relative risk: 0.65, 95% CI 0.50-0.85), SMM plus critical care admission (adjusted relative risk: 0.46, 95% CI 0.29-0.73), and respiratory morbidity (adjusted relative risk: 0.42, 95% CI 0.16-1.15); however respiratory morbidity was underpowered and had wide CIs, according to the authors.1

Further, the findings also demonstrated greater risk reductions (50%) in SMM in women who had a medical indication for epidural analgesia (adjusted relative risk: 0.50, 95% CI 0.34-0.72) compared with their non-indicated counterparts (adjusted relative risk: 0.67, 95% CI 0.43-1.03; P < .001). The investigators also observed more marked reductions (47%) in SMM in women who delivered preterm (adjusted relative risk: 0.53, 95% CI 0.37-0.76) compared with women who delivered at term or post-term (adjusted relative risk: 1.09, CI 95% 0.98-1.21; P < .001). In addition, the observed reduced risk of SMM with epidural analgesia was significantly more noticeable as gestational age at birth decreased in the whole cohort, and in women who had a medical indication for the epidural, according to the authors.1

“These findings substantiate the current practice of recommending epidural analgesia during labor to women with known risk factors, underscores the importance of ensuring equitable access to such treatment, and highlights the importance of supporting women from diverse backgrounds to be able to make informed decisions relating to epidural analgesia during labor,” the authors concluded.1

According to the authors, potential limitations of the study include few cases of respiratory morbidity, emphasizing a need for larger studies that examine this outcome; the exclusion of elective C-sections, the exclusion of other anesthesia methods; and the findings potentially strengthening the confidence in the effect between epidural analgesia and SMM. In addition, the authors note that data systemic opioid use and maternal hemodynamics data should be included in future research because both can be valuable in further explaining the mechanisms of epidural analgesia during labor and how it reduces the risk of SMM. The authors also note that the study’s population was primarily White due to the lack of representation within Scotland’s overall population, however, the study findings align with a similar study conducted in the US which enrolled a more diverse population.1

The findings suggest that epidural analgesia may be a practical protection option for women who have at-risk pregnancies, and women should consider this to improve maternal health outcomes.2

References

1. Kearns RJ, Kyzayeva A, Halliday LOE, Lawlor DA, Shaw M, Nelson SM. Epidural analgesia during labour and severe maternal morbidity: population based study. BMJ. 2024;385:e077190. doi:10.1136/bmj-2023-077190
2. Epidural linked to reduction in serious complications after childbirth. News release. British Medical Journal. May 22, 2024. Accessed May 28, 2024. https://www.eurekalert.org/news-releases/1045307
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