Does epidural analgesia during labor affect the incidence of cesarean delivery?

There is substantial evidence that there is an increased incidence of cesarean delivery among patients who receive epidural analgesia during labor. The controversy as to whether there is a causal relationship between epidural analgesia and cesarean delivery. Two prospective, randomized studies suggest that epidural analgesia may increase the incidence of operative delivery in laboring women. However, retrospective population-based studies suggest that the introduction of an epidural analgesia service, or the increased use of epidural analgesia, does not increase the cesarean delivery rate. It is possible that epidural analgesia during labor may increase the risk of cesarean delivery in selected patients. Such an effect--if it exists at all--appears to be small in contemporary practice. Furthermore, the availability and use of epidural analgesia may encourage other patients to undergo an adequate trial of labor or attempt vaginal birth after cesarean delivery. It is important to consider the impact of epidural analgesia on the total population of obstetric patients. Maternal-fetal factors and obstetric management, not epidural analgesia, are the most important determinants of the cesarean delivery rate. Finally, physicians should remember that pain relief is itself a worthy goal.