Developing a concise multivariable predictive model for cesarean delivery following neuraxial analgesia during labor: a prospective observational cohort study

Paula Daniele Lopes da Costa; Murilo Henrique da Veiga Ferreira; Joelcio Francisco Abbade; Claudia Garcia Magalhães; Norma Sueli Pinheiro Módolo; Guilherme Antonio Moreira de Barros; Gabriel Ricardo Correa Turco; Pedro Henrique Esteves Trindade; Paulo do Nascimento Junior

doi:10.1016/j.bjane.2026.844732

Original Investigation

Developing a concise multivariable predictive model for cesarean delivery following neuraxial analgesia during labor: a prospective observational cohort study

Desenvolvimento de um modelo preditivo multivariável conciso para cesariana após analgesia neuroaxial durante o trabalho de parto: estudo prospectivo observacional de coorte

Paula Daniele Lopes da Costa, Murilo Henrique da Veiga Ferreira, Joelcio Francisco Abbade, Claudia Garcia Magalhães, Norma Sueli Pinheiro Módolo, Guilherme Antonio Moreira de Barros, Gabriel Ricardo Correa Turco, Pedro Henrique Esteves Trindade, Paulo do Nascimento Junior

http://dx.doi.org/10.1016/j.bjane.2026.844732 Braz J Anesthesiol, vol.76, n3, 844732, 2026

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Abstract

Background

Sometimes, planned vaginal deliveries with neuraxial analgesia may result in unplanned cesareans. We aimed to determine the incidence of cesarean among parturients receiving neuraxial analgesia for vaginal delivery, identify associated factors, and develop a predictive model.

Methods

In this prospective observational cohort study, we evaluated parturients receiving neuraxial analgesia for vaginal delivery and analyzed factors associated with progression to cesarean. Multiple logistic regression with a step-up procedure was performed. The dataset was split into training (70%) and testing (30%) databases, with the latter used to assess performance metrics. Bootstrap validation with 5,000 repetitions was performed.

Results

We evaluated 331 parturients and 94 (28.4%) underwent cesarean. Variables differing between cesarean and vaginal delivery groups (p < 0.05) included patient age, body mass index, gestational age, cervical dilation at analgesia initiation, time under analgesia, labor conducted/monitored by nurses, and oxytocin use after analgesia initiation. Three variables remained predictive [odds ratio (95% Confidence Interval (95% CI))]: patient age: 1.0436 (1.0091 to 1.0835), p = 0.018; time under analgesia: 1.0043 (1.0008 to 1.0081), p = 0.018; and oxytocin use after analgesia initiation: 0.0921 (0.0400 to 0.1945), p < 0.001. Predictive area under the curve (95% CI) was 71.8% (60.5%‒83.1%). Arrest of descent (35.1%) and fetal distress (34.0%) were the leading indications for cesarean.

Conclusions

Among parturients receiving neuraxial labor analgesia, older patients, longer analgesia duration, and no oxytocin use after analgesia initiation increase the probability of cesarean, with moderate predictivity. Arrest of descent and fetal distress were the main causes of cesarean.

Keywords

Cesarean section; Epidural analgesia; Labor pain; Obstetric analgesia; Predictive values of tests

Resumo

Introdução

Às vezes, partos vaginais planejados com analgesia neuroaxial podem resultar em cesarianas não planejadas. Nosso objetivo foi determinar a incidência de cesarianas entre parturientes que receberam analgesia neuroaxial para parto vaginal, identificar fatores associados e desenvolver um modelo preditivo.

Métodos

Neste estudo prospectivo observacional de coorte, avaliamos parturientes submetidas à analgesia neuroaxial para parto vaginal e analisamos fatores associados à progressão para cesariana. Foi realizada regressão logística múltipla com procedimento step-up. O conjunto de dados foi dividido em bancos de treinamento (70%) e teste (30%), sendo este último utilizado para avaliar métricas de desempenho. Foi realizada validação bootstrap com 5.000 repetições.

Resultados

Foram avaliadas 331 parturientes, das quais 94 (28,4%) foram submetidas à cesariana. As variáveis que diferiram entre os grupos cesariana e parto vaginal (p < 0,05) incluíram idade materna, índice de massa corporal, idade gestacional, dilatação cervical no início da analgesia, tempo sob analgesia, trabalho de parto conduzido/monitorado por profissionais da enfermagem e uso de ocitocina após o início da analgesia. Três variáveis permaneceram preditivas [odds ratio (Intervalo de Confiança de 95% [IC 95%])]: idade materna: 1,0436 (1,0091 a 1,0835), p = 0,018; tempo sob analgesia: 1,0043 (1,0008 a 1,0081), p = 0,018; e uso de ocitocina após o início da analgesia: 0,0921 (0,0400 a 0,1945), p < 0,001. A área sob a curva preditiva (IC 95%) foi de 71,8% (60,5%‒83,1%). Parada de descida fetal (35,1%) e sofrimento fetal (34,0%) foram as principais indicações para cesariana.

Conclusão

Entre parturientes submetidas à analgesia neuroaxial durante o trabalho de parto, pacientes mais velhas, maior duração da analgesia e ausência de uso de ocitocina após o início da analgesia aumentam a probabilidade de cesariana, com preditividade moderada. Parada de descida fetal e sofrimento fetal foram as principais causas de cesariana.

Palavras-chave

Cesárea; Analgesia epidural; Dor do parto; Analgesia obstétrica; Valores preditivos de testes

References

1. Costley PL, East CE. Oxytocin augmentation of labour in women with epidural analgesia for reducing operative deliveries. Cochrane Database Syst Rev. 2013;7:CD009241.

2. Lieberman E, Lang JM, Cohen A, D’Agostino Jr. R, Datta S, Frigo- letto Jr. FD. Association of epidural analgesia with cesarean delivery in nulliparas. Obstet Gynecol. 1996;88:993−1000.

3. Wong CA, Scavone BM, Peaceman AM, et al. The risk of cesarean delivery with neuraxial analgesia given early versus late in labor. N Engl J Med. 2005;352:655−65.

4. Nakano T, Muto H, Ishii K, Hayashi S, Okamoto Y, Mitsuda N. Fac- tors associated with emergency cesarean delivery during induc- tion of labor in nulliparous women aged 35 years or older at term. J Obstet Gynaecol Res. 2018;44:1747−51.

5. Rydahl E, Declercq E, Juhl M, Maimburg RD. Cesarean section on a rise. Does advanced maternal age explain the increase? A pop- ulation register-based study. PLoS One. 2019;14:e0210655.

6. Son M, Lai Y, Bailit J, et al. Association between time of day and the decision for an intrapartum cesarean delivery. Obstet Gyne- col. 2020;135:535−41.

7. Carlson NS, Corwin EJ, Hernandez TL, Holt E, Lowe NK, Hurt KJ. Association between provider type and cesarean birth in healthy nulliparous laboring women: A retrospective cohort study. Birth. 2018;45:159−68.

8. Janssen PA, Stienen JJ, Brant R, Hanley GE. A predictive model for cesarean among low-risk nulliparous women in spontaneous labor at hospital admission. Birth. 2017;44:21−8.

9. Hernandez-Martinez A, Pascual-Pedreno AI, Bano-Garnes AB, Melero-Jimenez MR, Tenias-Burillo JM, Molina-Alarcon M. Predic- tive model for risk of cesarean section in pregnant women after induction of labor. Arch Gynecol Obstet. 2016;293:529−38.

10. Bujang MA, Sa’at N, Sidik T, Joo LC. Sample size guidelines for logistic regression from observational studies with large popula- tion: emphasis on the accuracy between statistics and parameters based on real life clinical data. Malays J Med Sci. 2018;25:122−30.

11. Bannister-Tyrrell M, Ford JB, Morris JM, Roberts CL. Epidural analgesia in labour and risk of caesarean delivery. Paediatr Peri- nat Epidemiol. 2014;28:400−11.

12. Lawson J, Amaratunge L, Goh M, Selvaratnam RJ. Perinatal out- comes after regional analgesia during labour. Aust N Z J Obstet Gynaecol. 2024;64:334−40.

13. Wang F, Shen X, Guo X, Peng Y, Gu X. Epidural analgesia in the latent phase of labor and the risk of cesarean delivery: a five-year randomized controlled trial. Anesthesiology. 2009;111:871−80.

14. Cunha AA, Portela MC, Amed AM, Camano L. Modelo preditivo para cesariana com uso de fatores de risco. Rev Bras Ginecol Obstet. 2024;24:21−8.

15. Smith GC, Cordeaux Y, White IR, et al. The effect of delaying child- birth on primary cesarean section rates. PLoS Med. 2008;5:e144.

16. He FY, Wang S. Epidural analgesia for labor: effects on length of labor and maternal and neonatal outcomes. Eur Rev Med Phar- macol Sci. 2023;27:130−7.

17. Behrens O, Goeschen K, Luck HJ, Fuchs AR. Effects of lumbar epidural analgesia on prostaglandin F2 alpha release and oxyto- cin secretion during labor. Prostaglandins. 1993;45:285−96.

18. Abrão KC, Francisco RPV, Miyadahira S, Cicarelli DD, Zugaib M. Elevation of uterine basal tone and fetal heart rate abnormali- ties after labor analgesia: a randomized controlled trial. Obstet Gynecol. 2009;113:41−7.

19. Anim-Somuah M, Smyth RM, Cyna AM, Cuthbert A. Epidural ver- sus non-epidural or no analgesia for pain management in labour. Cochrane Database Syst Rev. 2018;5:CD000331.

20. Thorp JA, Parisi VM, Boylan PC, Johnston DA. The effect of con- tinuous epidural analgesia on cesarean section for dystocia in nulliparous women. Am J Obstet Gynecol. 1989;161:670−5.

21. Cheng YW, Shaffer BL, Nicholson JM, Caughey AB. Second stage of labor and epidural use: a larger effect than previously sug- gested. Obstet Gynecol. 2014;123:527−35.

22. Clark A, Carr D, Loyd G, Cook V, Spinnato J. The influence of epi- dural analgesia on cesarean delivery rates: a randomized, pro- spective clinical trial. Am J Obstet Gynecol. 1998;179:1527−33.

23. Wong CA. Neuraxial Labor Analgesia: Does It Influence the Out- comes of Labor? Anesth Analg. 2017;124:1389−91.

24. Schick C, Spineli LM, Raio L, Gross MM. First assessed cervical dilatation: is it associated with oxytocin augmentation during labour? A retrospective cohort study in a university hospital in Switzerland. Midwifery. 2020;85:102683.

25. Espada-Trespalacios X, Ojeda F, Perez-Botella M, et al. Oxytocin administration in low-risk women, a retrospective analysis of birth and neonatal outcomes. Int J Environ Res Public Health. 2021;18:4375.

26. Son M, Roy A, Stetson BT, et al. High-dose compared with standard-dose oxytocin regimens to augment labor in nullip- arous women: a randomized controlled trial. Obstet Gyne- col. 2021;137:991−8.

27. Lin R, Shi P, Li H, Liu Z, Xu Z. Association between epidural anal- gesia and indications for intrapartum caesarean delivery in group 1 of the 10-group classification system at a tertiary maternity hospital, Shanghai, China: a retrospective cohort study. BMC Pregnancy Childbirth. 2021;21:464.

28. Kaul B, Vallejo MC, Ramanathan S, Mandell G, Phelps AL, Daf- tary AR. Induction of labor with oxytocin increases cesarean section rate as compared with oxytocin for augmentation of spontaneous labor in nulliparous parturients controlled for lum- bar epidural analgesia. J Clin Anesth. 2004;16:411−4.

29. Fischer JE, Bachmann LM, Jaeschke R. A readers’ guide to the interpretation of diagnostic test properties: clinical example of sepsis. Intensive Care Med. 2003;29:1043−51.

30. Boyle A, Reddy UM, Landy HJ, Huang CC, Driggers RW, Laughon SK. Primary cesarean delivery in the United States. Obstet Gynecol. 2013;122:33−40.

Submitted date:
04/30/2025

Accepted date:
01/05/2026