No increased risk of caesarean or instrumental delivery for nulliparous women who have epidural analgesia early in (term) labour.

Context Wassen and colleagues have published an article on a topic of great practical importance: Does epidural analgesia (EA) given early in labour (≤3 cm cervical dilatation) increase the risk of instrumental delivery, compared with EA administered later in labour? This is important because EA is the most effective labour analgesia, and, if the timing of its administration is not associated with any adverse consequences, then it should not be denied to women in early labour. Women who have EA during their labour, compared with women who have other forms of analgesia, are at increased risk of instrumental delivery (RR 1.38, 95% CI 1.24 to 1.53).1 Instrumental deliveries are associated with increased risks to women of vaginal/perineal trauma and anal sphincter damage, which may in turn lead to urinary incontinence, bowel and sexual problems. Many women will choose EA in spite of this risk. The challenge has been to fi nd management strategies for labouring women with EA that reduce the risk of instrumental delivery. Two such strategies involve delaying the administration of EA and discontinuing EA late in labour. Systematic reviews of both these interventions2 3 show no reduction in the risk of instrumental delivery but an increase in inadequate pain relief, something women are unlikely to fi nd acceptable when unaccompanied by any benefi t. Wassen and colleagues suggest that the results from the most recent review of the effects of timing of EA2 may not be convincing, with one of the reasons being ‘a too broad defi nition’ of early labour (<4 to 5 cm cervical dilatation). Hence, the purpose of their review was to determine whether there was any increased risk of instrumental delivery when EA was commenced when cervical dilatation was ≤3 cm.