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Grand Rounds

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

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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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Related ObG Topics:

Neuraxial Analgesia: What is the Statewide Variation in Usage?
Cochrane Review: What are the Risks and Benefits of Epidural Analgesia During Labor?
Does Epidural Anesthesia Impact the Second Stage of Labor?

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