Epidural Analgesia and Cesarean Delivery

To the Editor: The article by Fogel et al. [1] is an important contribution to the topic of epidural analgesia and cesarean delivery. Unfortunately, they seemed to have missed the opportunity to reveal some very important information. Selected demographics, such as diabetes and pregnancy-induced hypertension, are reported; however, details of labor, such as duration of stages and oxytocin use, are not. Although the authors report the cesarean rate for nulliparous dystocia (no change), they do not report any other information (including epidural rate), comparing multiparous with nulliparous patients despite large numbers of nulliparous patients available for analysis (961 before versus 1205 after). This omission makes the reported cesarean rate uninterpretable. The authors state that most of the care was given by rotating residents, albeit closely supervised by staff who did not change during the nearly 2.5 yr of the study. Nevertheless, this is no assurance that there was standardization of obstetrical practice. Although I would like to believe the results shown in their article, a complete unbeliever could claim that perhaps increases in cesarean rate caused by epidurals were masked by decreases in the rate due to changes in obstetrical practice. If further details regarding labor and obstetrical management had been presented, it would be much easier to refute this claim. Jordan Tarshis, MD, FRCPC Department of Anaesthesia; Sunnybrook and Women's College Health Sciences Centre; University of Toronto; Toronto, Ontario, Canada M4N 3M5