Breech delivery and epidural analgesia


Dear Sir,

This paper (Chadha et al. 1992) is a retrospective chart review of 1456 women with breech deliveries at one centre. We have several concerns with the conclusions drawn from this study.

Firstly, as with all retrospective reviews, there is no control group and there are no clearly defined criteria for inclusion in the epidural or non-epidural groups. Thus, the reasons for some patients receiving an epidural, and others not, are not discussed. This, as briefly outlined in the discussion, may have a major influence on the course of labour. Recent literature suggests that subjective pain experience, in early or latent stages of labour, are predictive of the duration of the latent and active phase, as well as predictive of obstetrical complications (Wuitchik et al. 1990). Patients who receive epidurals early in labour from choice may, therefore, have a different course of labour than those who receive it later.

Secondly, receiving an epidural anaesthetic is assumed to be a standardized procedure in this paper. An epidural is insertion of a catheter into the epidural space. The catheter perse does not in any way influence either pain or course of labour. The drugs used, how they are used, and where they are injected make the epidural effective or deleterious. There is no information in this paper about the type of local anaesthetics given to these patients, the concentration, volume and frequency of injection, or whether any other drugs such as opioids were used.

Much has happened in obstetric anaesthesia and analgesia over the last decade. Use of low concentration, high volume epidural injections and infusions of local anaesthetics, with or without addition of opioids, have completely changed the management of epidural analgesia in labour (Wuitchik et al. 1990; Chestnut 1988). It is of interest that only three references in the paper are from the anaesthesia literature. Studd's paper, which concluded that epidurals ‘prolong the second stage and increase forceps delivery rates’, has been questioned by many other authors (Doughty 1969; Walton & Reynolds 1984). The authors state that the ‘use of epidural analgesia results in a significant decrease in uterine contraction intensity during the active phase and the second stage of labour’ quoting Johnson et al. 1972. Johnson's paper deals with a completely different method of anaesthesia to that which is in normal practice today. Johnson's patients went through the whole first stage of labour without analgesia. After full dilatation of the cervix, the patient was given a spinal, or peridural caudal anaesthetic using a large volume of 1% Lidocaine, 15–18 ml, resulting in epidural anaesthesia which caused complete pelvic floor paralysis. Modern epidural analgesia does not result in pelvic floor paralysis to this degree, nor does it result in changes in uterine contractility (Brownridge 1988).

The reason for the increase in caesarean section rates here is not clear. The quoted papers do not support this outcome and in the same issue of your Journal, there is a paper discussing differences in patterns of practice amongst obstetricians with regard to using caesarean sections (Guillemette & Fraser 1992). Many factors contribute to the decision to section a particular patient, as has been amply demonstrated in this country by the Consensus Conference on Caesarean Sections. These factors are not discussed in the paper.

We consider that the conclusions drawn in this paper are not valid for The current practice of epidural analgesia. Also, the lack of information about the management of the epidurals means that valid conclusions about the effect of epidurals on the course of breech delivery cannot be drawn from this study.