Epidural analgesia in small for gestational age and growth restricted fetuses: Impact on emergency delivery for presumed fetal distress

Introduction: Epidural analgesia (EDA) is widely used for pain relief during labor. Concerns have been raised about its potential association with an increased risk of emergency delivery for presumed fetal compromise, particularly in fetuses with low birth weight. This study aimed to evaluate whether EDA increases the risk of emergency delivery for suspected fetal distress in small-for-gestational-age and fetal growth restricted fetuses. Methods: Retrospective cohort study conducted on singleton pregnancies with prenatal diagnosis of small-for-gestational-age or fetal growth restricted fetuses, delivering at ≥ 36 + 0 weeks at a tertiary care center between January 2020 and January 2024. The primary exposure was EDA; the primary outcome was emergency cesarean section or vacuum-assisted delivery due to presumed fetal distress, based on cardiotocographic findings. The secondary outcome was the incidence of a composite neonatal outcome defined as the occurrence of at least one of umbilical artery pH < 7.00, base excess < –12 mEq/L, 5-minute Apgar score < 7, or NICU admission. The two groups (EDA vs. non-EDA) were compared using the chi-square test for categorical variables and the Mann–Whitney U test for continuous variables. Multivariate logistic regression was used to control for confounders. Results: Among 310 eligible deliveries, 135 (43.5 %) received EDA. Emergency delivery for suspected fetal distress occurred in 16.5 % of cases. There were no significant differences in emergency delivery rates between the EDA and non-EDA groups (15.56 % vs 17.14 %; p = 0.759), nor within the small-for-gestational-age (13.4 % vs 13.9 %; p = 0.896) and the growth restricted fetuses (21.5 % vs 22.4 %; p = 0.874) subgroups. No significant difference in the composite adverse neonatal outcome was observed between the EDA and non-EDA groups (8.15 % vs 7.43 %; p = 0.814). Multivariate analysis confirmed no association between EDA and emergency delivery (p = 0.600), whereas nulliparity (p = 0.024) and U/C ratio > 0.8 (p = 0.004) emerged as independent risk factors. Composite neonatal outcomes were similar between groups. Conclusions: In this cohort of well-characterized small-for-gestational-age and fetal growth restricted fetuses, EDA was not associated with an increased risk of emergency delivery for suspected fetal distress. Individualized patient assessment and tailored management of labor analgesia remain crucial to ensure maternal and fetal safety.