24h-payday

Epidural Analgesia—a delicate dance between its positive role and unwanted side effects (Part Three)

[Editor's Note: This is the last in a series of three posts by Dr. Michael Klein regarding the research behind risks, benefits and realities of epidural analgesia.  To read Dr. Klein's first two posts, go here and here.]

Not all women are alike in labour and delivery:
Because the experience of labour pain, including severity, tolerance and contraction patterns, differs greatly among women, so does their ability to cope with the labour process.  In consequence, some women feel the need to receive epidural analgesia prior to the onset of active labour.  In some cases, the use of an early epidural will relax a woman enough to help her labour progress to the active phase and thereby lead to less subsequent medical interventions.  However, if used early without specific indications, a woman may find herself exposed to a larger range of interventions, including a caesarean birth.

Dealing with the reality of the labour ward:
Given this paradox and the severity of some of the side-effects of epidural analgesia, it is time to be honest about the full effects of this excellent technology: there is no such thing as a side-effect. There are only effects, some of which we like and some of which we don’t. When epidurals are used specifically to problem-solve, the risks of complications and other interventions are in fact reduced. When used routinely and mindlessly, epidural analgesia increases problems and adverse outcomes. Women need to be fully informed of this before agreeing to an epidural. Today, women are usually only informed of the direct consequences of epidural analgesia, such as a headache or even very rare neurological complications, but they are not often informed of the consequences that can occur if epidurals are given routinely or too early. They are rarely told about the potential deleterious effects of an epidural on the woman’s labour, nor the cascade of other interventions that might ensue. They are unlikely to be informed that an epidural will increase the demand on their nurse to pay greater attention to the technology and in consequence provide less hands-on support for the labouring woman. They are unlikely to be made aware of an epidural’s purported interference with the initial success of implementing breastfeeding following the baby’s birth.

Epidural analgesia is clearly an effective form of pain relief but it can also have less desirable consequences. Women need to be accurately and completely informed of their choices for pain relief in labour before they can provide their true consent. No matter how well intended, epidural analgesia increases the likelihood that women will have a variety of other interventions, especially if the epidural is given without specific medical indication. Women need to know that when epidural analgesia is given before the active phase of labour, it more than doubles the probability of a cesarean section.

The importance of timing and setting:
Women also need to be reassured that when epidural analgesia is given in the active phase of labour, it does not increase the cesarean section rate. This may motivate women to use other pain relief modalities and methods to help them, if possible, get to the active phase before requesting an epidural.

Readers of the literature also need to remember the importance of setting when reading about the research on epidural analgesia and any other interventions. All the statistics and outcomes that have been discussed here are in fact specific to the setting or environment from which the individual study or meta-analysis emanate. It is important to remember that adverse effects of epidural analgesia can be mitigated, especially if the setting generally limits the use of interventions. It appears, for example that in settings with low cesarean section rates (below 10%), even early epidurals do not increase the cesarean section rate,(21) but in more typical settings where cesarean section rates are higher than 20%, it does. This illustrates a general principle: For all studies, randomized or not, the reader needs to ask the question: do the caregivers in the studies practice the way that I do? If they do, the study may apply but if not, they may not.

The bottom line is that epidural analgesia has completely transformed birth. This massive change in the way that many women receive care in labour and birth has been based on a technique that, when used selectively and as a back-up tool or second line approach, is an important and valuable technique, among the many ways of assisting women with labour and birth. However, when used routinely as a first line agent, epidural analgesia can create problems that could have been avoided. Our Canadian National Study of the Attitudes and Beliefs of Maternity Care Providers has illuminated the very different ways that different disciplines view birth. (22) Most Canadian younger obstetricians (23)and women approaching their first birth (24) do not even know that epidural analgesia interferes with labour. The older generation of obstetricians knows that it does. They have experienced the changes related to epidural analgesia availability and usage during their many years in practice before and after the common use of epidural analgesia. It is time we told the truth about epidural analgesia – to colleagues and women – and engaged in a truly informed decision-making discussion with women about the optimal use of epidural analgesia.

References for this entire series of posts can be found here: References _ michael klein post

Post by:  Michael C. Klein, MD, CCFP, FAAP(Neonatal-Perinatal),FCFP, ABFP
Emeritus Professor of Family Practice and Pediatrics
University of British Columbia
Senior Scientist Emeritus
Centre Developmental Neuroscience and Child Health
Child and Family Research Institute
4500 Oak Street
Vancouver, V6H 3N1
Tel: 604-875-2000 ext 5078
Fax: 604-875-3569
Email:
mklein@interchange.ubc.ca

Epidural Analgesia, Evidence Based Medicine, Practice Guidelines, Research, Science & Sensibility, Uncategorized , , , , , , , , , , , ,

  1. March 4th, 2011 at 11:27 | #1

    Dr. Klein, thank you for such an informative series of posts!! Your thoughtful analysis is such a wonderful resource for all of us who care for women and their families. Any suggestions on how we get more docs to get on board?

  2. avatar
    Ruth
    March 4th, 2011 at 19:15 | #2

    Thank you, Dr. Klein, for tackling this important issue. Your thoughtful, careful analysis and your frank comments are helpful and welcome. Now, to get the word out to other doctors AND to expectant parents. I feel we have a big educational challenge ahead of us in order to shift attitudes about epidurals.

  3. March 6th, 2011 at 13:59 | #3

    I think that women should also be aware of other forces promoting epidurals that have nothing to do with their needs or preferences:

    “It is to the economic advantage of both the individual anesthesia provider and the hospital if a dedicated obstetrics analgesia/anesthesia service has already been established whose costs are spread over many procedures” (p. S179). (Marmor TR, Krol DM. Labor pain management in the United States: understanding patterns and the issue of choice. Am J Obstet Gynecol 2002;186(5 Suppl Nature):S173-80.)

    “Caring for an unmedicated mother requires one-on-one care. We don’t always have that luxury. With an epidural you have a lot more leeway because they’re comfortable. There’s a lot less you have to do immediately. When an unmedicated woman is ready to push, she’s ready to push and you’ve got to be there. It’s just more time intensive and more emotional. It kind of drains you, especially if they’re not handling it well” (p. 54). (Carlton T, Callister LC, Christiaens G, et al. Labor and delivery nurses’ perceptions of caring for childbearing women in nurse-managed birthing units. MCN Am J Matern Child Nurs 2009;34(1):50-6.)

    “If we put women in hospitals with restrictive policies—they’re hooked up to everything, they’re expected to be in bed—of course they’re going to go for the epidural. . . . They come to your hospital, and they have no choice. . . . They can’t manage their pain because you won’t let them (p. 174-5).” (Block J. Pushed: The Painful Truth About Childbirth and Modern Maternity Care. Cambridge, MA: Da Capo Press; 2007.) FYI: This last quotation is by Lamaze’s very own Judith Lothian, professor of nursing and co-author of The Official Lamaze Guide: Giving Birth With Confidence.

  4. avatar
    Kimberly
    March 7th, 2011 at 13:43 | #4

    That last paragraph is so interesting, our ideas of normal have changed. I did not realize that most women see an epidural as having zero negative effects on labor, that is something that definitely needs to be talked about more!

  5. avatar
    Gilbert J. Grant, MD
    March 7th, 2011 at 14:11 | #5

    After reading Dr. Klein’s posts, I have concluded that he is genuinely concerned about helping women in childbirth, and that he sincerely believes what he says. I may be wrong, but it seems to me that his heart is in truly the right place. Having said that, I must say that I have some serious concerns with some of his statements, and I think that women who read them, to the exclusion of considerable published data that do not support his statements, may be misled.
    Without going into excruciating detail, allow me to illustrate what I mean by three examples:
    “They [women] are unlikely to be made aware of an epidural’s purported interference with the initial success of implementing breastfeeding following the baby’s birth.”
    I am glad that Dr. Klein used the word “purported,” which is defined as “claimed or alleged.” This allegation is “common knowledge” among natural birth enthusiast, but it is certainly not a fact. I have used epidurals AFTER birth to encourage breast-feeding in women who experience severe after-pains. A couple of women recently commented on the severity of her after-pains in posts – one of whom had homebirths. So I purport that epidurals ENCOURAGE moms to nurse their newborns. How many women are told about this?
    “Women need to know that when epidural analgesia is given before the active phase of labour, it more than doubles the probability of a cesarean section.”
    I would be very curious to see a well-conducted prospective, randomized controlled trial (i.e., science) that supports this claim that epidurals CAUSE doubling of the probability of cesarean section. As it happens, there are well-conducted, prospective, randomized controlled trials that show that epidural and spinal pain relief given before the active phase of labor HAVE NO EFFECT ON THE RATE OF CESAREAN SECTION.
    “Most Canadian younger obstetricians (23)and women approaching their first birth (24) do not even know that epidural analgesia interferes with labour. The older generation of obstetricians knows that it does.”
    I would say that it’s quite a good thing that these younger obstetricians don’t know that epidurals interfere with labor. Because they don’t interfere with labor! One of the problems here is that the older generation may still remember the older epidurals that were commonly used. Over the past 20 years, most hospitals have switched over to the “walking” epidurals (or “walking” spinals, or “walking combined spinal-epidurals”).
    If you want to learn more about this topic, and are willing to keep an open mind, check out my new book, EPIDURAL WIHTOUT GUILT: CHILDBIRTH WITHOUT PAIN. If you’re not interested in opening your mind to ideas you may not have considered, don’t read it – it will probably just tick you off!

  6. March 7th, 2011 at 15:34 | #6

    @ Dr. Grant and all,

    In re-reading Dr. Klein’s entire series on this topic, I found Dr. Grant’s question is quite succinctly answered:

    I would be very curious to see a well-conducted prospective, randomized controlled trial (i.e., science) that supports this claim that epidurals CAUSE doubling of the probability of cesarean section.

    In the second post in the series, Dr. Klein explains the link between epidural analgesia and malpositioning of the fetus [due to relaxation of the pelvic floor musculature] which can then, presumably, lead to poor engagement and descent of the fetus and, eventually, an increased risk for cesarean. Dr. Klein also directly discusses the Cochrane ’04 and ’05 Collaboration studies and explains how he and his colleagues analyzed the separate studies contained within the 2004 review–ultimately recalculating the numbers to separate out–and more accurately represent–study participants’ risk of cesarean section based on early vs. late epidural placement. Thus, the understanding of a doubled risk of cesarean when epidurals are placed prior to the onset of active labor. Go here to see all references for Dr. Klein’s three-part series of posts.

    Speaking from a practical stand point, I have witnessed and heard of numerous scenarios that go something like this: epidural is successfully placed with analgesic infusion initiated==>mother’s blood pressure suddenly drops==>fetus establishes a concerning heart rate decel pattern during contractions==>decels continue, accompanied by heightened concern on the part of the health care team==>mother undergoes an “emergency c-section” soon thereafter.

    Regardless of whether or not this scenario is depicted in any current/recent study, ask any doula, childbirth educator or L&D nurse and I guarantee you, s/he will confirm having witnessed this same scenario. And likely more than once.

    Dr. Klein never states in his series of posts that epidurals are evil, egregious nor worthy of universal expunging. In fact, he summarizes his thoughts on epidurals this way:

    The bottom line is that epidural analgesia has completely transformed birth. This massive change in the way that many women receive care in labour and birth has been based on a technique that, when used selectively and as a back-up tool or second line approach, is an important and valuable technique, among the many ways of assisting women with labour and birth. However, when used routinely as a first line agent, epidural analgesia can create problems that could have been avoided.

    The other bottom line here, I think, is that any medical intervention that is OPTIONAL should be approached with complete and utter informed consent–the woman, in this case, ought to be completely informed of all the benefits and risks of epidural analgesia so that, when all is said and done, she can feel as though she was a true decision maker during the process of her baby’s birth. That way, if one of the multiple known risks associated with epidural analgesia occurs, she can feel satisfied that she was aware of the risk, rather than surprised by the occurrence of the complication.

    One additional question I invite Dr. Grant (or others) to expand upon: can you share with us your references to studies conducted on immediate postpartum women (say, within the first week following birth) in which epidural analgesic medication levels have been measured in breastmilk? Should a nursing woman find herself contemplating using epidural analgesia for pain control following birth, I imagine she would want to know the findings of any such studies–so that she can be assured her infant is not being exposed to additional medications (fetanyl, for example) which are commonly used in epidurals.

  7. avatar
    Gilbert J. Grant, MD
    March 7th, 2011 at 17:23 | #7

    Thank you, Ms. Hull, for your comments. Please allow me to respond to some of your points. You wrote “Dr. Klein explains the link between epidural analgesia and malpositioning of the fetus [due to relaxation of the pelvic floor musculature] which can then, presumably, lead to poor engagement and descent of the fetus and, eventually, an increased risk for cesarean.” Not only is this not a succinct answer to my question, it is not an answer at all. I would say that the key words here are “link” and “presumably.” For a scientist, these words indicate that a “leap of faith” is required to say that epidurals increase the risk of cesarean section. The data are simply not there. I had a very specific request. I said “I would be very curious to see a well-conducted prospective, randomized controlled trial (i.e., science) that supports this claim that epidurals CAUSE doubling of the probability of cesarean section.” He has not provided reference to such a trial, nor have you. It’s because there are no such data. No matter. It’s the old “don’t confuse the argument with facts” approach. Some people will still believe that epidurals cause cesareans until the cows come home. And no amount of scientific evidence to the contrary will dissuade them. Nothing I can do about that, except I think it is important to make this clear so that women considering their options for childbirth will take this into account when deciding whether or not to use an epidural or a spinal.
    With regard to your point about an epidural causing maternal hypotension and fetal decelerations: this for sure can happen, but it shouldn’t nowadays – not with labor analgesia, anyway. I discuss the risks of epidural and spinal-induced hypotension in my book. But this is unlikely to occur with a properly conducted “walking” epidural, like the one I have used routinely in my practice for the last 20 years.
    With regard to your question about medications such as fentanyl getting into the breast milk. There are some data on this. For example, in 1992, Phyllis L Steer, et al published their results in the Canadian Journal of Anaesthesia (39:231-235). They gave approximately 150 micrograms of fentanyl to women undergoing cesarean or postpartum tubal ligation and measured concentration in colostrums and found that peak concentrations occurred at the first sampling time (45 minutes) but were fairly low, and that by ten hours the levels were virtually undetectable. Here’s what I would say is important about the issue you raise: ANYTHING that a mom takes will get into her breast milk. Typically, it’s only a small fraction of the dose she takes. But here’s what’s important to realize: If the new mom is in significant pain, she will want to take something to relieve that pain. And given the choices she has available, an epidural is an excellent one, because such low concentrations of medication are required to provide really good pain relief. That’s because the medication is administered exactly where it needs to be – in close proximity to the nerves that carry the pain signals. The net effect? A relatively small dose of medication achieves a large degree of pain relief. A much better choice than, say, a systemic narcotic. That would tend to make the mom sleepy (and probably make the baby sleepy as well. With an epidural, the mom is awake, and the baby is awake. Nice, eh? And remember, I’m not recommending this for ALL women – heavens, no! Only for those that have significant post-partum pain. For some of these women, severe after-pains may dissuade them from breast-feeding. For other women, severe post-partum pain from cesarean or from a traumatic vaginal delivery may distract them from focusing on their newborn. Why not make them completely comfortable so that they can devote all of their energy to their newborn baby? I use a REALLY low dose, so that the new moms can walk around without difficulty. I realize people don’t usually consider this approach, but don’t you think that they should?
    Thanks again for your comments!

  8. avatar
    Andrea
    March 7th, 2011 at 21:46 | #8

    I have read Dr. Grant’s postings and would like to comment on his statement about “walking” epidurals. I have heard of such an animal but in my time as a midwifery student with placements in 5 major Canadian hospitals, I have yet to see one. I asked one of the staff anesthesiologists about it one day and he laughed and said – “But then you would have me up here every hour to adjust it….” I believe that some of the negative effects of epidurals would be lessened if women had movement (use of catheters, prolonged second stage to name two). I would love to see the anesthesia community embrace this concept more frequently.

    And to your comment that Dr. Klein’s statement about the impact of epidurals increasing the c-section rate being invalid because it is not supported by a RCT – such an RCT cannot ever take place as it would be unethical to randomize women to receiving/not receiving an epidural prior to labour. So you are correct, there is no such data, and there never will be. However, observational data is not without validity, and any practitioner can provide case after case of slowed labours, persistent OP babies, women unable to push effectively with their contractions because they can’t feel them, and other situations where c-section is the ultimate result after an epidural. Would these cases have been c-sections anyway? We can never know, but to completely rule out correlation seems as “unscientific” as you claim Dr. Klein is being.

    I whole-heartedly agree with Dr. Klein – epidurals are a tool in our obstetric toolkit, and when they are needed, they can work wonders, and on occasion allow an exhausted mother the rest she needs to deliver vaginally. When they are used when less invasive strategies would be as effective, they can create more problems than they solve.

  9. avatar
    comadrona
    March 7th, 2011 at 23:37 | #9

    As a midwife in a busy hospital, who also attends homebirths, I would have to say I have NEVER seen an epidural used for after-birth pains! Pethidine used to be the drug of choice in years gone by, and still is in the private sector, but it has deleterious effects on breast feeding -i.e. sleepy baby and unfocused mother with supressed milk ejection reflex. It is important to note that after-pains can be alleviated with hot-packs and oral analgesia and are self-limiting. To use an epidural in this case I think would be overkill, considering one then has all the risks associated with epidurals in labour, even if the dose is smaller. I wonder whether even a lower dose would effectively shut down the woman’s own endorphin and oxytocin production as it so often does in labour. This lack translates to poorer bonding and often delayed breast feeding for reasons like post-surgical recovery (in the case of C/S) or suturing (because the woman was supine and sustained greater perineal trauma), or because the baby needed resucitation as a result of distress after the “cascade of intervention”. I’m not knocking epidurals wholesale – they can (occasionally) be just the ticket, but a woman is much better off relying on loving support and trust of her body in labour – commodities which are admittedly in short supply at the average hospital birth.

  10. avatar
    Gilbert J. Grant, MD
    March 8th, 2011 at 00:01 | #10

    Thanks, comadrona. There are some women in whom hot packs and oral anlgesics just don’t cut it, and an ultra-low dose epidural, such as the on I use, can transform the entire experience, and encourage breast-feeing in a woman who otherwise would be reticent to do so. I realize this is not common practice – but I think women should consider it. Check the comments of “Diane” and “Mom of 3″ on this blog: http://blogs.babble.com/being-pregnant/2011/02/09/epidural-advocate-says-we-should-get-epidurals-after-the-birth-too/#more-16955
    What I am proposing is nothing less than a re-think of the issue: epidurals to encourage the liklihood of successsful breast-feeding!

  11. March 8th, 2011 at 10:14 | #11

    Dr. Grant, I am curious as to what percentage of women you think your post-birth epidural is good for? In all my years helping women, I have yet to meet one who says that afterpains have anything to do with breastfeeding decisions. It simply has never been a factor.
    So while I can see your theoretical point, I worry greatly that this is adding to the amount of pharmacological intervention in birth, without addressing any of the real reasons women struggle to breastfeed.

  12. avatar
    Gilbert J. Grant, MD
    March 8th, 2011 at 12:45 | #12

    Hi Nicole: Great question! As I mentioned above, I am in no way suggesting postpartum epidurals for all women – “heavens no!” – as I said. But there are some women who would benefit. Two such women happened to comment on the babble.com blog that I referenced above. I am only suggesting postpartum epidural analgesia for those women who experience moderate-to-severe pain after delivery, because moderate-to-severe pain is probably not good for encouraging successful breastfeeding. For one thing, we know that pain decreases the amount of milk let down. Also, the new mom who is experiencing severe pain may not be as attentive to her newborn as the mom who is comfortable. Most humans, when they’re in pain, just want to curl up in bed and be left alone. So, to answer your question – which women in particular would benefit from a postpartum epidural? Well, for starters, any woman who has had a cesarean. Post-operative cesarean pain hurts. At my hospital that’s 29% of all our births! At some other hospitals the percentage is even higher. Who else may benefit? Women who have had traumatic vaginal deliveries with significant damage to the vagina, perineum and anus. Also women who have had a non-traumatic vaginal delivery, but who have had many previous babies. This is because after-pains tend to worsen with each successive delivery. I was surprised to find that the after-pains can be much worse than labor for some of these moms. And I have cared for women who have been afraid to breast-feed, and even decided not to breast-feed, simply because of the anticipated pain. One described the after-pains as so severe that she was afraid she would not be able to hold her baby. Now, of course there are other choices for pain relief for all of the cases I have outlined. But let’s be clear: epidural pain relief is the optimal choice with regard to effectiveness for the mother and safety for the baby. The ultra-low dose I use allows the mother to walk around as much as she desires, and it doesn’t make her sleepy, so the baby is awake, too. If the mom can take a non-steroidal or acetaminophen, great. No need for the epidural. But the pain I am describing, moderate-to-severe pain, is typically not well-controlled by these means, and narcotics are used. Narcotics make the mother sleepy, and they will therefore likely make the nursing baby sleepy as well. And, they don’t relieve the pain that well, either. I refer to this as “the worst of both worlds.” By the way, since most the women at my hospital get epidurals anyway, I don’t need to put one in just to manage the postpartum pain – I simply leave the one in that they already have. And as I mentioned, I use an ultra-low dose so walking isn’t a problem, and I give everyone a button so they can self-administer their medication as they see fit; having control over the situation is a very important component of one’s sense of well-being.

  13. March 8th, 2011 at 14:13 | #13

    I kind of think epidural’s for afterbirth pain is overkill also. I’ve worked for four years now in a very busy hospital, and I have never seen a need for that kind of pain control. Perhaps maybe for c-sections. But we also use narcotics, which kill the pain, but I’m not sure of their effects on breastfeeding.

    I do think it is an interesting idea though. And that perhaps we could look more into doing research in this area. Part of the problem I see with using epidurals for afterpains is that afterpains last a lot longer than a stay in the hospital. If we were to use epidurals for afterpains I think it would be my absolute line of defense. There are so many other effective, non-medicated ways to deal with afterpains. For instance , hot water does wonders. Also , distraction would be a good way to deal with this as these pains are not continuous.

    I think that before we start spending more time on money on research for epidurals and afterpain , I would rather spend it on other non-invasive and less expensive ways of dealing with it.

  14. avatar
    Gilbert J. Grant, MD
    March 8th, 2011 at 15:01 | #14

    Hi Ms. Leavitt: Thank you for your comments. Let me tell you, for those women with severe after-pains that I’ve care for; their postpartum epidurals were not overkill. They were a Godsend. You can read the comments that I alluded to above on the babble.com blog. Narcotics are not great pain killers, and of course they have many side effects. Most problematic for a new mom is their propensity to induce drowsiness – in the mother and the baby (via breast milk transfer). The women with severe after pains that I’ve cared for (usually after baby # 3 , 4, 5 or more) take a narcotic every 3 to 4 hours, but still have significant pain. These women are the best candidates for an epidural. If a hot water bottle or distraction works, they certainly don’t need an epidural. But neither of those methods reliably relieves moderate-to-severe pain. By the way the epidural I use is NOT continuous. There is a catheter in, of course, but the mom gives herself her own dose at the start of breast-feeding by pressing her epidural patient controlled analgesia (EPCA) button.

  15. March 8th, 2011 at 15:56 | #15

    Dr. Grant-So this works like a PCA then? And is the cost worth it? How long do these women stay in the hospital? Would they have to stay longer? And how much nursing care is involved in this? Do they need the same kind of monitoring that a PCA pump would need because that is a whole lot more intensive nursing care and requires an almost one on one staffing model for the first little bit at least. Even after the first few hours of using a PCA, more intensive nursing care is needed. And then what would they do when they go home. That would also be difficult to implement in smaller hospitals that don’t always have an anesthetist at the hospital or have the staff to do this. If this is only used for those who have severe after birth pain(which I don’t know the exact numbers, and I have never really asked women if there pain is so great that they don’t feel like they could nurse), would it be feasible to cover the cost for just one or two patients out of 20-30?

    I think your idea is intriguing, actually, I’m just not sure I see a big need for it or if it is worth the time and money that could potentially be involved. The women that I have seen that have had the most problems with pain and nursing are those who have had c-sections. I could see them using it. Other than that narcotics seem to cover it. Sometimes not all of the pain, but enough to allow them to nurse comfortably. I guess the big question for me, in terms of nursing, is how much do narcotics effect nursing, and would using an epidural actually help some women who have severe pain increase the odds of nursing? If it really and truly helped women to nurse better and improved the rates of nursing, then I could see the benefits outweighing the cost. Otherwise, I’m not sure. It would be interesting to see how women would feel about this and if it is something that would help.

  16. March 8th, 2011 at 18:25 | #16

    Dr Klein,
    This thread has been somewhat hijacked by Dr. Grant…
    I am curious if you have any response to my original question – how can we get hospital staff on board? I know (as Ruth said above) that we have to also get parents on board – but I am already doing that (as a childbirth educator). But quite often parents are dismayed to find out that the hospital staff WANT them to get an epidural. I have heard staff say things like “oh, you don’t want an epidural? you must have been taking those prenatal classes. don’t worry, there is no reason not to get one. they are perfectly safe”
    How can we get your message to hospital staff?

  17. avatar
    Gilbert J. Grant, MD
    March 8th, 2011 at 18:51 | #17

    Hi Ms. Leavitt: Yes. The epidural I use for after-pains is not just like a PCA – it is PCA . I don’t use a basal infusion at all. Women give themselves a dose just before nursing and then again if they were to need it. When you ask about the cost being worth it, I must say, it’s not something that I think about much. Fortunately, I work in a large academic center, and we are able to do this. I have a very simplistic approach when it comes to treatment. I try to treat everyone as if they were a member of my family. If a member of my family had severe after-pains, they would keep their epidural in to treat them, so that’s what I do for my patients. I realize it’s a bit different in countries with socialized medicine systems. We’re not quite there yet in the U.S., so for the time being I am able to use the optimal pain management. Women at my hospital typically stay two days after vaginal delivery. They can leave the epidural in until a couple of hours before they go home on PPD#3. So it helps them a lot for the first couple of days. With regard to nursing, there is no greater nursing care needed than the standard postpartum care. At my hospital, we have been using postpartum epidural PCA for 15 years, so the nurses are very familiar with it. Because it is an ultra-low dose medication formulation, it is quite safe. Remember, at my hospital our section rate is approx 30%, so we use are using epidural PCA after well over 1,000 cesareans per year. We have a pain service – someone around 24/7. I’m not saying that this could work easily in a small community hospital. But there are a lot of large hospitals where it could work – if there was the desire to institute such a service. With regard to the effect on nursing, I think about it in very simple terms: if the mom is sleepy from narcotics, there’s a decent chance the baby is going to be sleepy as well. If the mom is awake, there’s a decent chance the baby will be awake as well. Epidural pain relief is superior to narcotic pain relief in nursing moms.

  18. avatar
    Gilbert J. Grant, MD
    March 8th, 2011 at 23:52 | #18

    Hi Andrea: I just now noticed your post. We’ve been using “walking” epidurals at my hospital for about 20 years now. Although I must tell you most patients don’t walk much – but that’s another story. They do have the ability to do so and certainly to walk to the bathroom and to get into various positions during labor and delivery. I agree with you that using low-dose epidurals is a good thing. I would hope that everyone would use them. Dr. Klein was specifically discussing the issue of the use of early versus late epidurals and the effect on the cesarean rate. Those studies are not unethical to do, and in fact over the past few years, such studies have been done – including one involving nearly 13,000 women. And those studies showed that epidurals and combined epidural-spinals DO NOT increase the cesarean rate. My challenge was to tell me about a study of early versus late epidurals that shows it DID increase the cesarean rate. But there isn’t such a study, because early epidurals DO NOT increase the cesarean rate. There are some interesting studies that look at the general question of epidural or no epidural on cesarean rate (in other words, forgetting the early versus late in labor question). A whole bunch of studies have been done where an institution was looked at BEFORE and AFTER epidural use either became available or increased dramatically. I review one of these studies in my book, which was done at Trippler Army Hospital in Hawaii. There are at least nine others. A total of nearly 40,000 deliveries. And the findings in every case are similar: the institution or dramatic increase in epidural availability was not associated with an increase in the rate of cesarean section. The issue has been decided – except, of course that facts don’t mean a whole lot to people who would rather ignore them. Beware of “observational data.” It is very weak. For example, I can tell you about many obstetricians who swear up and down that in “Mrs. So-and-so, we put in an epidural and her labor took off.” Does that mean any more than the stories about other moms-to-be who had their labors essentially halted by epidurals. All of this is called anecdotal evidence, and, scientifically speaking, it is very weak. We need properly conducted trials to reach meaningful conclusions. With regard to epidurals causing cesareans, the trial are done, and it’s clear that there is no causative link between epidurals and cesareans. I’m not saying everyone needs an epidural. But it’s really unfair to distort the data so that someone considering getting one is given the impression that if she gets an epidural, her chances of cesarean increase. Its simply not true.

  19. avatar
    Gilbert J. Grant, MD
    March 9th, 2011 at 06:11 | #19

    *******I posted this on the wrong thread – I meant to post a reply to Andra here*************
    Hi Andrea: I just now noticed your post. We’ve been using “walking” epidurals at my hospital for about 20 years now. Although I must tell you most patients don’t walk much – but that’s another story. They do have the ability to do so and certainly to walk to the bathroom and to get into various positions during labor and delivery. I agree with you that using low-dose epidurals is a good thing. I would hope that everyone would use them. Dr. Klein was specifically discussing the issue of the use of early versus late epidurals and the effect on the cesarean rate. Those studies are not unethical to do, and in fact over the past few years, such studies have been done – including one involving nearly 13,000 women. And those studies showed that epidurals and combined epidural-spinals DO NOT increase the cesarean rate. My challenge was to tell me about a study of early versus late epidurals that shows it DID increase the cesarean rate. But there isn’t such a study, because early epidurals DO NOT increase the cesarean rate. There are some interesting studies that look at the general question of epidural or no epidural on cesarean rate (in other words, forgetting the early versus late in labor question). A whole bunch of studies have been done where an institution was looked at BEFORE and AFTER epidural use either became available or increased dramatically. I review one of these studies in my book, which was done at Trippler Army Hospital in Hawaii. There are at least nine others. A total of nearly 40,000 deliveries. And the findings in every case are similar: the institution or dramatic increase in epidural availability was not associated with an increase in the rate of cesarean section. The issue has been decided – except, of course that facts don’t mean a whole lot to people who would rather ignore them. Beware of “observational data.” It is very weak. For example, I can tell you about many obstetricians who swear up and down that in “Mrs. So-and-so, we put in an epidural and her labor took off.” Does that mean any more than the stories about other moms-to-be who had their labors essentially halted by epidurals. All of this is called anecdotal evidence, and, scientifically speaking, it is very weak. We need properly conducted trials to reach meaningful conclusions. With regard to epidurals causing cesareans, the trial are done, and it’s clear that there is no causative link between epidurals and cesareans. I’m not saying everyone needs an epidural. But it’s really unfair to distort the data so that someone considering getting one is given the impression that if she gets an epidural, her chances of cesarean increase. Its simply not true.

  20. March 13th, 2011 at 05:41 | #20

    @Nicole
    Nicole: You ask such a fundamental question. I am afraid that hospital staffs will not change easily. The revolution in the 1970s that led to partners in the birth, great reductions in routine episiotomy and shaving and edema and other inhumane insults was led by women not staff or maternity providers and resulted in what we now call “Family Centered Maternity care.” Unfortunately many thought that the battle was over. The revolutionaries are now in their 60s and 70s. They seem not to be worried about their 30 year plus old daughters having their first baby. They ought to be.

    And women are so afraid of birth that they seemingly will put up with anything. Unless we help them to see that lack of informed decision-making is a women’s health issue, nothing will change and we will move to the fully industrailized birth so well described in the Wang paper that Dr. Grant uses, among others, to say that epidurals are not a problem when used early and often.

    Revolutionary hospital staff may help but it is hard to make a revolution when few are unhappy. Where choice exists, thoughtful women go to midwives and the few family docs still in the game. The rest go to obstetricians and accept what is on offer. After the fact (birth), they may have post-traumatic stress disorder, but then it is too late. Doulas may moderate PTSD, if they can manage to moderate the hospital environment but they cannot do the job alone.

    In our current internet-based research on knowledge transformation, we attempt to arm women with the information that they need to have an adult conversation with whomever is looking after them for the birth,

  21. avatar
    Nicole
    March 14th, 2011 at 13:06 | #21

    @Michael Klein

    “It is hard to make a revolution when few are unhappy”

    So true!
    I was just saying to one of my colleagues the other day, that I am glad our birth rate has gone down slightly. In the large booming city where I work,the number of births has been so high for the last few years, that there was no way women could choose a provider based on philosophical similarities – they simply saw anyone who would take them on and be thrilled to have a doctor. In the last 8 months or so we are seeing doctor’s practices that are not completely full – which is a wonderful opportunity for women to be able to choose a provider who is a good fit for them. (We have only a few midwives unfortunately, and they are generally full with previous clients before most women have even peed on a stick).
    So – I guess I will just keep my nose to the grindstone (so to speak, as I love it more than anything!!) and keep offering women information on all the fabulous choices they have…
    Thanks for this amazing series!

  22. avatar
    Ozmidwife
    May 12th, 2011 at 13:40 | #22

    I’ve been a midwife for 20 years and I have never seen a woman not want to breastfeed due to severe afterpains. They are usually managed well with simple analgesia, a hot pack and some patience.

  1. April 18th, 2011 at 05:21 | #1
  2. May 5th, 2011 at 14:40 | #2
  3. August 8th, 2012 at 16:53 | #3