ACOG Committee
Opinion
Committee on
Obstetric Practice
Reaffirmed 2010
Number 339, June 2006 (Replaces No. 269, February 2002)
This document reflects emerging
Analgesia and Cesarean
clinical and scientific advances as
of the date issued and is subject to Delivery Rates
change. The information should
not be construed as dictating an ABSTRACT: Neuraxial analgesia techniques are the most effective and least
exclusive course of treatment or depressant treatments for labor pain. The American College of Obstetricians
procedure to be followed. and Gynecologists previously recommended that practitioners delay initiat-
Copyright © June 2006 ing epidural analgesia in nulliparous women until the cervical dilatation
by the American College of reached 4–5 cm. However, more recent studies have shown that epidural
Obstetricians and Gynecologists. analgesia does not increase the risks of cesarean delivery. The choice of
All rights reserved. No part of this analgesic technique, agent, and dosage is based on many factors, including
publication may be reproduced, patient preference, medical status, and contraindications. The fear of unnec-
stored in a retrieval system, post- essary cesarean delivery should not influence the method of pain relief that
ed on the Internet, or transmitted, women can choose during labor.
in any form or by any means,
electronic, mechanical, photo- Neuraxial analgesia techniques (epidural, spinal, and combined spinal–epidur-
copying, recording, or otherwise, al) are the most effective and least depressant treatments for labor pain (1, 2).
without prior written permission Early studies generated concern that the benefits of neuraxial analgesia may
from the publisher.
be offset by an associated increase in the risk of cesarean delivery (3, 4).
Requests for authorization to Recent studies, however, have determined that when compared with intra-
make photocopies should be venous systemic opioid analgesia, the initiation of early neuraxial analgesia
directed to:
does not increase the risk of cesarean delivery (5–7).
Copyright Clearance Center In 2000, the American College of Obstetricians and Gynecologists
222 Rosewood Drive (ACOG) Task Force on Cesarean Delivery recommended that “when feasi-
Danvers, MA 01923
(978) 750-8400 ble, obstetric practitioners should delay the administration of epidural anes-
thesia in nulliparous women until the cervical dilatation reaches at least 4–5
ISSN 1074-861X cm” (8). This recommendation was based on earlier studies, which suggest-
The American College of ed that epidural analgesia increased the risk of cesarean delivery by as much
Obstetricians and Gynecologists as 12-fold (3, 4, 9, 10). Furthermore, certain studies demonstrated an even
409 12th Street, SW greater association between epidural analgesia and cesarean delivery in
PO Box 96920
Washington, DC 20090-6920 women who received their epidurals before reaching cervical dilatation of
5 cm (3, 9). In 2002, an evaluation of cesarean delivery sponsored by ACOG
Analgesia and cesarean delivery rates. concluded, “there is considerable evidence suggesting that there is in fact an
ACOG Committee Opinion No. 339. association between the use of epidural analgesia for pain relief during labor
American College of Obstetricians and the risk of cesarean delivery (8).
and Gynecologists. Obstet Gynecol
2006;107:1487–8. Since the last Committee Opinion on analgesia and cesarean delivery,
additional studies have addressed the issue of neuraxial analgesia and its
association with cesarean delivery. Three recent meta-analyses systematical-
ly and independently reviewed the previous litera- 3. Thorp JA, Hu DH, Albin RM, McNitt J, Meyer BA,
ture, and all concluded that epidural analgesia does Cohen GR, et al. The effect of intrapartum epidural anal-
gesia on nulliparous labor: a randomized, controlled,
not increase the rates of cesarean delivery (odds ratio prospective trial. Am J Obstet Gynecol 1993;169:851–8.
1.00–1.04; 95% confidence interval, 0.71–1.48) 4. Ramin SM, Gambling DR, Lucas MJ, Sharma SK, Sidawi
(11–13). In addition, three recent randomized con- JE, Leveno KJ. Randomized trial of epidural versus intra-
trolled trials clearly demonstrated no difference in venous analgesia during labor. Obstet Gynecol 1995;
rate of cesarean deliveries between women who had 86:783–9.
5. Wong CA, Scavone BM, Peaceman AM, McCarthy RJ,
received epidurals and women who had received Sullivan JT, Diaz NT, et al. The risk of cesarean delivery
only intravenous analgesia (5–7). Furthermore, a with neuraxial analgesia given early versus late in labor.
randomized trial comparing epidurals done early in N Engl J Med. 2005;352:655–65.
labor versus epidurals done later in labor demonstrat- 6. Sharma SK, Alexander JM, Messick G, Bloom SL,
ed no difference in the incidence of cesarean delivery McIntire DD, Wiley J, et al. Cesarean delivery: a random-
ized trial of epidural analgesia versus intravenous meperi-
(17.8% versus 20.7%) (5). The use of intrathecal dine analgesia during labor in nulliparous women.
analgesia and the concentration of the local anes- Anesthesiology 2002;96:546–51.
thetic used in an epidural also have no impact on the 7. Halpern SH, Muir H, Breen TW, Campbell DC, Barrett J,
rate of cesarean delivery (5, 13–15). Liston R, et al. A multicenter randomized controlled trial
Therefore, ACOG reaffirms the opinion it pub- comparing patient-controlled epidural with intravenous
analgesia for pain relief in labor. Anesth Analg 2004;
lished jointly with the American Society of 99:1532–8.
Anesthesiologists, in which the following statement 8. American College of Obstetricians and Gynecologists.
was articulated: “Labor causes severe pain for many Evaluation of cesarean delivery. Washington, DC: ACOG;
women. There is no other circumstance where it is 2000.
considered acceptable for an individual to experi- 9. Lieberman E, Lang JM, Cohen A, D’Agostino R Jr, Datta
S, Frigoletto FD Jr. Association of epidural analgesia with
ence untreated severe pain, amenable to safe inter- cesarean delivery in nulliparas. Obstet Gynecol 1996;
vention, while under a physician’s care. In the 88:993–1000.
absence of a medical contraindication, maternal 10. Howell C, Chalmers I. A review of prospectively con-
request is a sufficient medical indication for pain trolled comparisons of epidural with non-epidural forms
relief during labor” (16). The fear of unnecessary of pain relief during labour. Int J Obstet Anesth
1992;1:93–110.
cesarean delivery should not influence the method of 11. Leighton BL, Halpern SH. The effects of epidural analge-
pain relief that women can choose during labor. sia on labor, maternal, and neonatal outcomes: a systemic
The American College of Obstetricians and review. Am J Obstet Gynecol 2002;186:S69–77.
Gynecologists recognizes that many techniques are 12. Liu EH, Sia AT. Rates of caesarean section and instru-
available for analgesia in laboring patients. None of mental vaginal delivery in nulliparous women after low
concentration epidural infusion or opiod analgesia: sys-
the techniques appears to be associated with an temic review. BMJ 2004;328:1410.
increased risk of cesarean delivery. The choice of 13. Sharma SK, McIntire DD, Wiley J, Leveno KJ. Labor
technique, agent, and dosage is based on many fac- analgesia and cesarean delivery: an individual patient
tors, including patient preference, medical status, meta-analysis of nulliparous women. Anesthesiology
and contraindications. Decisions regarding analge- 2004;100:142–8.
14. Effect of low-dose mobile versus traditional epidural
sia should be closely coordinated among the obste- techniques on mode of delivery: a randomised controlled
trician, the anesthesiologist, the patient, and skilled trial. Comparative Obstetric Mobile Epidural Trial
support personnel. (COMET) Study Group UK. Lancet 2001;358:19–23.
15. Chestnut DH, McGrath JM, Vincent RD Jr, Penning DH,
Choi WW, Bates JN, et al. Does early administration of
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