Research Article| Volume 34, ISSUE 3, e286-e291, May 2021

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Epidural analgesia during birth and adverse neonatal outcomes: A population-based cohort study

  • Diana Høtoft
    Corresponding author.
    Department of Obstetrics and Gynaecology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
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  • Rikke Damkjær Maimburg
    Department of Obstetrics and Gynaecology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark

    Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark

    School of Nursing and Midwifery, Western Sydney University, Locked Bag 1797, Penrith 2751, Australia
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      In general, epidural analgesia is considered a safe and efficient way to relieve pain during active labour and is increasingly used in childbirth. It is well documented that epidural analgesia during birth has benefits but also adverse effects. However, evidence is limited on how epidural analgesia influences neonatal outcome in a low-risk population of birthing women.


      To examine low Apgar score, foetal hypoxia and admission to the neonatal intensive care unit in neonates of low-risk women receiving epidural analgesia during birth.


      A cohort study using registry data to investigate a population of 23,272 low-risk women giving birth at a university hospital.


      Epidural analgesia was used in 21.6% of low-risk women during birth. Low Apgar score, foetal hypoxia, and admission to the neonatal intensive care unit were found in 0.6%, 0.6%, and 10.0%, respectively in neonates of mothers receiving epidural analgesia during birth compared to 0.3%, 0.6%, and 5.6%, respectively in the non-exposed group. Epidural analgesia was associated with low Apgar score, adjusted odds ratio 1.76 (95% CI 1.07–2.90) and admission to the neonatal intensive care unit, adjusted odds ratio 1.43 (95% CI 1.26–1.62). A mediation analysis indicates the impact of epidural analgesia on adverse neonatal outcomes was mediated by obstetric complications like maternal fever, labour augmentation, and foetal malpresentation.


      This study found use of epidural analgesia during birth in low-risk pregnant women was associated with infant low Apgar score and admission to the neonatal intensive care unit.



      EA (epidural analgesia), BMI (body mass index), NICU (neonatal intensive care unit), PROM (prelabour rupture of membranes)
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        • Anim-Somuah M.
        • Smyth R.M.
        • Cyna A.M.
        • Cuthbert A.
        Epidural versus non-epidural or no analgesia for pain management in labour.
        Cochrane Database Syst. Rev. 2018; 5
        • Jones L.
        • Othman M.
        • Dowswell T.
        • Alfirevic Z.
        • Gates S.
        • Newburn M.
        • et al.
        Pain management for women in labour: an overview of systematic reviews.
        Cochrane Database Syst. Rev. 2012; 3
        • Brownridge P.
        Treatment options for the relief of pain during childbirth.
        Drugs. 1991; 41: 69-80
        • Herrera-Gomez A.
        • Garcia-Martinez O.
        • Ramos-Torrecillas J.
        • De Luna-Bertos E.
        • Ruiz C.
        • Ocana-Peinado F.M.
        Retrospective study of the association between epidural analgesia during labour and complications for the newborn.
        Midwifery. 2015; 31: 613-616
        • Reynolds F.
        The effects of maternal labour analgesia on the fetus. Best practice & research.
        Clin. Obstet. Gynaecol. 2010; 24: 289-302
        • Riley L.E.
        • Celi A.C.
        • Onderdonk A.B.
        • Roberts D.J.
        • Johnson L.C.
        • Tsen L.C.
        • et al.
        Association of epidural-related fever and noninfectious inflammation in term labor.
        Obstet. Gynecol. 2011; 117: 588-595
        • Hasegawa J.
        • Farina A.
        • Turchi G.
        • Hasegawa Y.
        • Zanello M.
        • Baroncini S.
        Effects of epidural analgesia on labor length, instrumental delivery, and neonatal short-term outcome.
        J. Anesth. 2013; 27: 43-47
        • Tornell S.
        • Ekeus C.
        • Hultin M.
        • Hakansson S.
        • Thunberg J.
        • Hogberg U.
        Low Apgar score, neonatal encephalopathy and epidural analgesia during labour: a Swedish registry-based study.
        Acta Anaesthesiol. Scand. 2015; 59: 486-495
        • Segal S.
        Labor epidural analgesia and maternal fever.
        Anesth. Analgesia. 2010; 111: 1467-1475
        • Sharpe E.E.
        • Arendt K.W.
        Epidural labor analgesia and maternal fever.
        Clin. Obstet. Gynecol. 2017; 60: 365-374
        • Shatken S.
        • Greenough K.
        • McPherson C.
        Epidural fever and its implications for mothers and neonates: taking the heat.
        J. Midwifery Women's Health. 2012; 57: 82-85
        • Mortensen L.M.
        • Bech B.H.
        • Nohr E.A.
        • Kruhøffter M.
        • Kjærsgaard S.
        • Uldbjerg N.
        • et al.
        Data resource profile: the Aarhus Birth Cohort biobank (ABC biobank).
        Int. J. Epidemiol. 2013; 42: 1697-1701
        • American Academy of Pediatrics Committee on fetus and newborn
        • Gynecologists committee on Obstetric Practice
        The Apgar Score.
        Pediatrics. 2015; 136: 819-822
        • Lee A.C.
        • Kozuki N.
        • Blencowe H.
        • Vos T.
        • Bahalim A.
        • Darmstadt G.
        • et al.
        Intrapartum-related neonatal encephalopathy incidence and impairment at regional and global levels for 2010 with trends from 1990.
        Pediat. Res. 2013; 74: 50-72
        • Gillam-Krakauer M.
        • Gowen Jr., C.W.
        Birth Asphyxia. StatPearls (Internet).
        StatPearls Publishing, Treasure Island (FL)2019 (Last update: November 8)
        • Costley P.L.
        • East C.E.
        Oxytocin augmentation of labour in women with epidural analgesia for reducing operative deliveries.
        Cochrane Database Syst. Rev. 2012; 5
        • O’Hana H.P.
        • Levy A.
        • Rozen A.
        • Greemberg L.
        • Shapira Y.
        • Sheiner E.
        The effect of epidural analgesia on labor progress and outcome in nulliparous women.
        J. Maternal-Fetal Neonatal Med. 2008; 21: 517-521
        • Okazaki A.
        • Fukushima R.
        • Nagashima S.
        • Mazda Y.
        • Tamura K.
        • Terui K.
        • et al.
        Outcomes of labor epidural analgesia among women aged over 40: A single-institution retrospective study.
        J. Obstet. Gynaecol. Res. 2016; 42: 1712-1718
        • Albers L.L.
        The duration of labor in healthy women.
        J. Perinatol. 1999; 19: 114-119
        • Hayashi K.
        • Matsuda Y.
        • Kawamichi Y.
        • Shiozaki A.
        • Saito S.
        Smoking during pregnancy increases risks of various obstetric complications: a case-cohort study of the Japan perinatal registry network database.
        J. Epidemiol. 2011; 21: 61-66
        • Verdiales M.
        • Pacheco C.
        • Cohen W.R.
        The effect of maternal obesity on the course of labor.
        J. Perinatal Med. 2009; 37: 651-655
        • Berglund S.
        • Grunewald C.
        • Pettersson H.
        • Cnattingius S.
        Risk factors for asphyxia associated with substandard care during labor.
        Acta Obstet. Gynecol. Scand. 2010; 89: 39-48
        • Greenland S.
        • Pearl J.
        • Robins J.M.
        Causal diagrams for epidemiologic research.
        Epidemiology. 1999; 10: 37-48
        • Lieberman E.
        • Lang J.
        • Richardson D.K.
        • Frigoletto F.D.
        • Heffner L.J.
        • Cohen A.
        Intrapartum maternal fever and neonatal outcome.
        Pediatrics. 2000; 105: 8-13
        • Lieberman E.
        • O’Donoghue C.
        Unintended effects of epidural analgesia during labor: a systematic review.
        Am. J. Obstet. Gynecol. 2002; 186: S31-S68
        • Lieberman E.
        • Davidson K.
        • Lee-Parritz A.
        • Shearer E.
        Changes in fetal position during labor and their association with epidural analgesia.
        Obstet. Gynecol. 2005; 105: 974-982
        • Sharma S.K.
        • Rogers B.B.
        • Alexander J.M.
        • McIntire D.D.
        • Leveno K.J.
        A randomized trial of the effects of antibiotic prophylaxis on epidural-related fever in labor.
        Anesth. Analgesia. 2014; 118: 604-610
        • Caughey A.B.
        • Sharshiner R.
        • Cheng Y.W.
        Fetal malposition: impact and management.
        Clin. Obstet. Gynecol. 2015; 58: 241-245
        • Wassen M.M.
        • Winkens B.
        • Dorssers E.M.
        • Marcus M.A.
        • Moonen R.M.
        • Roumen F.J.
        Neonatal sepsis is mediated by maternal fever in labour epidural analgesia.
        J. Obstet. Gynaecol. 2014; 34: 679-683
        • Morris J.M.
        • Totterdell J.
        • Bin Y.S.
        • Ford J.B.
        • Roberts C.L.
        Contribution of maternal age, medical and obstetric history to maternal and perinatal morbidity/mortality for women aged 35 or older.
        Aust. N. Zeal. J. Obstet. Gynaecol. 2018; 58: 91-97
      1. World Health Organization (Internet), Obesity: preventing and managing the global epidemic, Report of a WHO consultation, available from (accessed 10.11.19).

        • Greenwell E.A.
        • Wyshak G.
        • Ringer S.A.
        • Johnson L.C.
        • Rivkin M.J.
        • Lieberman E.
        Intrapartum temperature elevation, epidural use, and adverse outcome in term infants.
        Pediatrics. 2012; 129: e447-e454
        • Osborne C.
        • Ecker J.L.
        • Gauvreau K.
        • Davidson K.M.
        • Lieberman E.
        Maternal temperature elevation and occiput posterior position at birth among low-risk women receiving epidural analgesia.
        J. Midwif. Women's Health. 2011; 56: 446-451
        • Ekeus C.
        • Hjern A.
        • Hjelmstedt A.
        The need for epidural analgesia is related to birthweight - a population-based register study.
        Acta Obstet. Gynecol. Scand. 2009; 88: 397-401
        • Dickinson J.E.
        • Paech M.J.
        • McDonald S.J.
        • Evans S.F.
        The impact of intrapartum analgesia on labour and delivery outcomes in nulliparous women.
        Aust. N. Zeal. J. Obstet. Gynaecol. 2002; 42: 59-66
        • Allanson E.R.
        • Waqar T.
        • White C.
        • Tuncalp O.
        • Dickinson J.E.
        Umbilical lactate as a measure of acidosis and predictor of neonatal risk: a systematic review.
        BJOG: Int. J. Obstet. Gynaecol. 2017; 124: 584-594
        • Malin G.L.
        • Morris R.K.
        • Khan K.S.
        Strength of association between umbilical cord pH and perinatal and long term outcomes: systematic review and meta-analysis.
        BMJ (Clin. Res. Ed.). 2010; 340: c1471
        • French C.A.
        • Cong X.
        • Chung K.S.
        Labor epidural analgesia and breastfeeding: a systematic review.
        J. Human Lact. 2016; 32: 507-520
        • Brimdyr K.
        • Cadwell K.
        • Widstrom A.M.
        • Svensson K.
        • Neumann M.
        • Hart E.A.
        • et al.
        The association between common labor drugs and suckling when skin-to-skin during the first hour after birth.
        Birth. 2015; 42: 319-328