Epidural analgesia initiated early in labor (when the cervix is less than 4.0 cm dilated) has been associated with an increased risk of cesarean delivery. It is unclear, however, whether this increase in risk is due to the analgesia or is attributable to other factors. We conducted a randomized trial of 750 nulliparous women at term who were in spontaneous labor or had spontaneous rupture of the membranes and who had a cervical dilatation of less than 4.0 cm. Women were randomly assigned to receive intrathecal fentanyl or systemic hydromorphone at the first request for analgesia. Epidural analgesia was initiated in the intrathecal group at the second request for analgesia and in the systemic group at a cervical dilatation of 4.0 cm or greater or at the third request for analgesia. The primary outcome was the rate of cesarean delivery. The rate of cesarean delivery was not significantly different between the groups (17.8 percent after intrathecal analgesia vs. 20.7 percent after systemic analgesia; 95 percent confidence interval for the difference, -9.0 to 3.0 percentage points; P=0.31). The median time from the initiation of analgesia to complete dilatation was significantly shorter after intrathecal analgesia than after systemic analgesia (295 minutes vs. 385 minutes, P<0.001), as was the time to vaginal delivery (398 minutes vs. 479 minutes, P<0.001). Pain scores after the first intervention were significantly lower after intrathecal analgesia than after systemic analgesia (2 vs. 6 on a 0-to-10 scale, P<0.001). The incidence of one-minute Apgar scores below 7 was significantly higher after systemic analgesia (24.0 percent vs. 16.7 percent, P=0.01). Neuraxial analgesia in early labor did not increase the rate of cesarean delivery, and it provided better analgesia and resulted in a shorter duration of labor than systemic analgesia. Copyright 2005 Massachusetts Medical Society.