Epidural in Labour and Obstetric Anal Sphincter Injury Risk: A Systematic Review and Meta‐Analysis

Background Perineal injury during childbirth is common. The most severe injuries involve damage to the anal sphincter (obstetric anal sphincter injuries). Epidural analgesia provides effective labour pain relief but its impact on the risk of obstetric anal sphincter injury is unclear. Objective To determine the association between epidural analgesia and the likelihood of obstetric anal sphincter injuries. Search Strategy Ovid MEDLINE, Ovid EMBASE, PubMed, CINAHL and Web of Science were searched from database inception to October 18, 2025, using key words relating to epidural, perineal trauma and labour. Selection Criteria Randomised trials and observational studies (cohort, case–control, and cross‐sectional studies) were included. Data Collection and Analysis Studies reporting the same outcomes were pooled, and odds ratios with 95% confidence intervals were calculated using a random effects meta‐analysis. Main Results From 24 977 identified studies, 86 were included ( N = 9 826 330 women). Pooled adjusted analyses showed epidural use in labour was associated with a 15% reduced likelihood of obstetric anal sphincter injury in the overall population ( n = 9 302 188; aOR 0.85 [95% CI 0.80–0.91]). Among nulliparous women, there was a 23% reduced likelihood of obstetric anal sphincter injury ( n = 1 083 923; aOR 0.77 [95% CI 0.71–0.83]). Conclusion After pooling effect measures that corrected for important clinical confounders, our meta‐analysis suggests that epidural use in labour may reduce the likelihood of obstetric anal sphincter injuries among nulliparous women. While our findings must be interpreted within the limitations of observational data, they provide valuable evidence to guide clinical practice and highlight the need for more high‐quality studies to establish causality. Trial Registration PROSPERO Registration CRD42023412771, 09 April 2023 https://www.crd.york.ac.uk/PROSPERO/view/CRD42023412771