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)

METHODS:

• 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)

RESULTS:

• 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%)

CONCLUSION:

• 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

Learn More – Primary Sources:

Use of Labor Neuraxial Analgesia for Vaginal Delivery and Severe Maternal Morbidity

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