Risk factors for labor epidural conversion failure requiring general anesthesia for cesarean delivery

Background and aims: To evaluate the rate and risk factors of labor epidural conversion failure requiring general anesthesia for Caesarean delivery (CD).

Material and methods: Pregnant patients requiring conversion from labor to CD with a pre-existing labor epidural at our institution from 2009 to 2014 were identified. Through a retrospective review, we compared successful epidural conversion with those who required general anesthesia for CD. Patient characteristics were analyzed to identify risk factors for failed epidural conversion for CD.

Results: A total of 673 patients were included in the study. The rate of epidural conversion failure was 21%. Main risk factors for epidural conversion failure requiring general anesthesia included: younger maternal age (95% CI 0.94, P = 0.0002) and supplementation of intravenous fentanyl (95% CI 0.19, P < 0.0001) or midazolam (95% CI 0.26, P = 0.0008) during CD. A higher risk of conversion failure was also associated with a more urgent CD (CD category 1, 2, and 3 vs category 4).

Conclusion: Consistent with previous reports, young age and the urgency of CD increases the likelihood of epidural conversion failure. While conversion failure is likely multifactorial and complex, many of these factors are suggestive of inadequate and poorly functioning labor epidurals prior to CD. Prospective studies to further evaluate these factors are necessary, and the best prevention of epidural conversion failure is diligent diagnosis and evaluation of ineffective labor epidural analgesia prior to impending CD.