Grand Rounds

Does Epidural Use During Vaginal Delivery Reduce the Risk of Severe Maternal Morbidity?

BACKGROUND AND PURPOSE:

Guglielminotti et al. (JAMA Network Open, 2022) assessed the association between the use of labor neuraxial analgesia for vaginal delivery and Severe Maternal Morbidity (SMM)

Population-based cross-sectional study
- Data derived from hospital discharge records from New York between January 2010 and December 2017
Population
- 5 to 49 years
- Undergoing first vaginal delivery
Exposures
- Neuraxial analgesia: Epidural or combined spinal-epidural
- No neuraxial analgesia
Study design
- Odds ratios (OR) of SMM associated with neuraxial analgesia were estimated using inverse propensity score–weighting and stratified according to
  - Race and ethnicity (non-Hispanic White vs racial and ethnic minority women, including non-Hispanic Asian or Pacific Islander, non-Hispanic Black, Hispanic, and other race and ethnicity)
  - The comorbidity index for obstetric patients (low-risk vs high-risk women)
Primary outcome
- Severe maternal morbidity (SMM)
Secondary outcome
- Postpartum hemorrhage (PPH)

575,524 included women
- Mean age: 26 (SD, 6) years
- Race/ethnicity
  - Non-Hispanic Asian or Pacific Islander: 8.0%
  - Non-Hispanic Black: 15.4%
  - Hispanic: 18.2%
  - Non-Hispanic White: 44.9%
  - Other race and ethnicity: 13.0%
- Comorbidity index
  - Low-risk: 69.6%
  - High-risk: 30.4%
- Received neuraxial analgesia: 47.4%
Incidence of SMM and PPH
- SMM: 1.3%
  - Of these, PPH: 35.6%
Incidence of SMM by neuraxial analgesia exposure, before weighting
- With neuraxial analgesia: 1.3%
- No neuraxial analgesia: 1.4%
There was a decreased risk of SMM associated with neuraxial analgesia
- Risk difference for SMM: −0.21% (95% CI, −0.30 to −0.12)
- Adjusted OR 0.86 (95% CI, 0.82 to 0.90)
This association was similar between
- Non-Hispanic White women and racial and ethnic minority women
- Low-risk and high-risk women
More than one-fifth of the observed association of neuraxial analgesia with the risk of SMM was mediated through the decreased risk of PPH
- 21% (95% CI, 14 to 28%)

Neuraxial analgesia exposure during vaginal delivery is associated with a 14% decreased risk of severe maternal morbidity
- This associated risk reduction was similar across race, ethnicity, and comorbidity index
- More than 20% of the observed SMM risk reduction was due to a decreased risk of PPH
Limitations of the study include
- Oservational design which demonstrates association but not causation | Only intrapartum SMM documented, not the 15% of severe adverse outcomes that occur following discharge
The authors suggest the following reasons why neuraxial analgesia may reduce PPH and SMM
- Earlier evaluation and management of early PPH due to enhanced maternal monitoring and early detection of blood loss following delivery
- Good IV access
- Continuous anesthesia availability and oversight

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