In Reply:—

Dr. Leighton suggests that epidural analgesia for labor is an optional service for which anesthesiologists will not be compensated appropriately until there is some financial benefit to the insurance industry to reimburse for this method of analgesia. These benefits already exist.

Epidural analgesia alleviates labor pain more effectively than do parenteral opioids and results in higher ratings of patient satisfaction. 1,2In the competition for patients, reimbursing for labor epidurals makes insurers attractive to women, the usual healthcare decision makers in the family. The risk of cesarean section does not differ between women who receive epidural analgesia and those who receive parenteral opioid analgesia. 1,2Access to epidural analgesia actually may decrease the cesarean section rate by encouraging women to attempt vaginal delivery after cesarean section. 3 

Do epidurals increase the duration of labor? In the randomized controlled trials examining this question, most patients were administered fluid preloads of 500–1,000 ml and lidocaine test doses, followed by initiation of block with 0.25% bupivacaine, 1,2producing a denser block than many obstetric anesthesiologists today would use in nulliparous women in the first stage of labor. Even if current low-dose epidural analgesia resulted in an increase in duration of labor, it is unlikely to affect cost. Just as recovery room time, decreasing the duration of labor by 1 or even 2 h cannot decrease costs significantly unless nurse staffing is reduced as a result.

Epidural analgesia has been associated with maternal temperature increase. 4The contribution of placental inflammation versus  impaired thermoregulation is not clear, with some evidence that fever, in the absence of histopatholgic evidence of chorioamnionitis, is not significantly different between patients with or without epidural analgesia. 5 

As Dr. Chestnut notes in his introduction to the second edition of the textbook Obstetric Anesthesia: Principles and Practice , 6our obstetric colleagues have negotiated equitable reimbursement for their services in some states. Perhaps it is time for anesthesiologists to do the same.

Halpern SH, Leighton BL, Ohlsson A, Barrett JFR, Rice A: Effect of epidural vs parenteral opioid analgesia on the progress of labor: A meta-analysis. JAMA 1999; 280: 2105–10
Howell CJ: Epidural versus non-epidural analgesia for pain relief in labour (Cochrane Review). The Cochrane Library. Oxford: Update Software, 2000, issue 3
American College of Obstetricians and Gynecologists: Vaginal delivery after a previous cesarean birth. ACOG Committee Opinion, October 1994
Camann WR, Hortuet LA, Hughes N, Bader AM, Datta S: Maternal temperature regulation during extradural analgesia for labor. Br J Anaesth 1991; 67: 565–8
Dashe JS, Rogers BB, McIntire DD, Levenko KJ: Epidural analgesia and intrapartum fever: Placental findings. Obstet Gynecol 1999; 93: 341–4
Chestnut, DH: Obstetric Anesthesia: Principles and Practice, 2nd edition. St Louis, Mosby, 1999, p xiii