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The Complete Illustrated Birthing Companion: A Book Review

September 10th, 2013 by avatar

I recently had the opportunity to review a book published in January, 2013, written for birthing families. The Complete Illustrated Birthing Companion; A Step-by-Step Guide to Creating the Best Birthing Plan for a Safe, Less Painful, and Successful Delivery for You and Your Baby.  This book is authored by a diverse team of experts, Amanda French, M.D., an OB/Gyn, Susan Thomforde, CNM, Jeanne Faulkner, RN and Dana Rousmaniere, author of pregnancy and birth topics. I wanted to share my review with Science & Sensibility readers so you can consider if you want to add this book to your recommended reading list for expecting families. The book is available on Amazon for 14.29 and a Kindle version is available as well.

This book is marketed as a large 8 1/2 by 11 inch paperback with an attractive cover.  Inside is easy to read print, a pleasant amount of white space on semi-glossy paper, along with full color photographs and illustrations.  There are some beautiful photographs in there, clearly taken by talented photographers, but some of the photos seemed too unnatural, women posed in the perfect position, wearing make-up with hair just so.  The pictures are all completely modest, with the exception of just one woman in a birth tub, which surprised me in a book about birth.  In my experience, birth is a bit more “gritty” than represented by the pictures chosen for this book.  I really appreciated the diversity of images of the women and their families, women of color and their families are well represented throughout. I also appreciated the choice of language, women have partners and those partners can be men or women.

Who is this book for?

This book for is for women who are still deciding on a birth along the spectrum of options, from a home birth to a planned cesarean. It also makes sense for women who are not quite sure what type of birth they want; they can read about all the choices as they settle on what feels good to themselves and their families.  The book is written in easy to understand language, and when medical vocabulary is introduced, a definition is provided so that readers can be clearly understand what is being discussed.  The book is best used for determining what type of birth a woman is interested in having.  If the mother has already determined where and how she would like to birth,  then this book, which is in large part a comparison of the different options, would be less useful.

Jeanne Faulkner, RN

What will families find inside?

The book starts off by asking women to imagine their perfect birth, encouraging them to hold this in their minds, but to also remember that birth requires flexibility as things can change during a pregnancy or labor that will require a deviation from what a mother was planning.  A brief but accurate overview of provider types (and a good list of questions to ask providers to determine who is right for each mother) and childbirth education options are covered, and states Lamaze includes a “good, comprehensive overview of childbirth.”  The chapters are then divided into options by birth location as well as pain medication choices, and then goes on to cover induction, planned and unplanned cesarean. Natural coping techniques and pharmacological pain medication options are covered in a chapter toward the end, along with a guideline for writing a birth plan.

“Unmedicated Vaginal Birth at Home” or “Epidural, Vaginal Birth in the Hospital” are some of the chapter titles and for each section the authors take the time to explain what this option is, why it may or may not be right for any particular woman (in the case of home birth, why a woman  might risk out of this option prenatally or in labor), the pros and cons of each option and how to best prepare if this is the choice a woman has made.  Throughout the book, the authors take care to state that women should be flexible and things may change. Desiring an epidural but not having time for one is a possibility that women need to consider.  I really appreciate this gentle reminder throughout the book, as I too believe that being flexible and being able to deviate from what a woman originally planned will help as the labor unfolds.

For each type of birth, women are given suggestions to help them achieve the birth they want and are encouraged to have a variety of coping techniques lined up for dealing with labor pain if they are choosing to go unmedicated.  Realistic and useful advice is given, even when the birth is highly managed, so that the mother and her partner can have a positive experience.

Amanda French, M.D.

What families won’t find inside?

This is not a book about pregnancy, breastfeeding, postpartum care or newborn care and it doesn’t claim to be.  This is a book about birth and the choices surrounding birth.  Families who want to read about prenatal testing, or learn about breastfeeding techniques will want to have other books in their collection that cover those topics.  While this book does a nice job covering the different options, birth locations and provider choices available to them,  it does so in a very matter of fact way.  There is not a lot of “rah-rah you can do it” language or encouragement for women to stretch for a low intervention option.  On one hand, it is nice to have the facts. On the other hand, evidence shows that for normal, low risk women, the less interventions the better for both mother and baby.  I am not sure that parents will walk away with that message after reading this book.

Would I recommend this book?

While providing a nice general overview of birth choices, I felt like there were several times that the authors wrote that women should trust their care provider’s expert recommendations versus becoming more informed and discussing all options, including the right to informed refusal.

For example, in the small section on episiotomy, it reads “How do I decide whether I want an episiotomy or a tear?  The short answer is this: You don’t make that decision, your provider does…If your provider decides an episiotomy is absolutely necessary, for example, to get the baby out more quickly, then so be it.  Your provider makes that decision based on the medical situation at hand.”  No mention of informing the woman, seeking consent or alternatives to cutting, for example changing position or waiting.

One of the authors, Dr. Amanda French also states several times that she stands with ACOG’s statement on homebirth (which is that birth should occur in a hospital or birth center attached to a hospital) and does not believe that having a baby at home is safe. She does acknowledge a woman’s right to make the decision on birth location for herself.  In reading the chapter on home birth, this bias does come through.

Dana Rousmaniere

In my opinion, the book is written through the health care provider’s lens.  Doulas are promoted- but readers are warned to watch out for those doulas who may have a “strong personal agenda” and parents are encouraged to work with experienced doulas, instead of doulas-in-training or those just starting out.  Birthing women are asked to let the anesthesiologist attempt two epidural placements, (if the first one does not work due to the mother having a “challenging back” or “not being in the ideal position”) before asking for another doctor to try.  Women are told to follow the recommendations of health staff in several places in the book.  Families are told that their newborn will have antibiotic eye ointment and hepatitis B vaccines administered.

In the chapter on VBACs, women are told that a con of VBAC-ing is that ”Vaginal delivery can result in tears in the vagina, which can be repaired immediately after delivery but may result in pain for several weeks after birth.”  Isn’t this a risk of any vaginal delivery?  For the families that I work with, I try to have mothers (and their partners) view themselves as a more equal partner in the decisions that are being made during labor and birth.

In summary

Overall, this book does a fair job of representing what to expect in eight different labor and birth scenarios, who might be a good candidate for each option and how best to be prepared.  Women can read and get assistance in choosing what might be the best option for them. Information on coping techniques and even pictures of good labor positions to try are well organized for easy reference.  For a woman who is undecided about where she wants to birth, this book will help her to understand the differences and the pros and cons of each location and type of birth, along with who attends births in each location.  For women who are have more clarity on what type of birth they want, I might make a different birth book recommendation.

Have you read this book?  Can you share your thoughts and opinion in our comments section?

 

Book Reviews, Epidural Analgesia, Home Birth, informed Consent, Maternity Care, Medical Interventions, Midwifery, Pain Management, Vaginal Birth After Cesarean (VBAC) , , , , , , , , , , , ,

Does Epidural Analgesia Predispose to Persistent Occiput Posterior?

February 14th, 2013 by avatar

Photo by Patti Ramos Photography

In my January Science and Sensibility blog post, I answered the question “Can We Prevent Persistent Occiput Posterior?” but because it wasn’t relevant to the study that prompted the post, and the piece was already long, I didn’t look at the role of epidural analgesia. Let me now rectify that.

All five studies examining the relationship between epidural analgesia and persistent occiput posterior (OP) find an association between them. Three studies compared women with an epidural versus no epidural according to whether they had an OP baby at delivery and found that 4 to 10 more women per 100 having an epidural had an OP baby at delivery (Cheng, 2006; Lieberman, 2005; Sizer, 2000). The other two compared women with an OP baby at delivery according to whether they had an epidural and found that 13 and 27 more women per 100 with a persistent OP baby had an epidural (Fitzpatrick, 2001; Ponkey, 2003).

Their results, however, aren’t sufficient to convict epidurals because we can’t tell whether having an epidural led to persistent OP or more painful and prolonged OP labor led to having an epidural. Investigators in one of the five studies argued for OP labor coming first on the grounds that while epidurals were more common in women with an OP baby at delivery than in women with an OA baby at delivery (74% vs. 47%) at their institution, a rise in epidural use from 3% in 1975 to 47% in 1998 had, if anything, decreased the hospital’s overall rate of persistent OP (4% vs. 2%) (Fitzpatrick, 2001). This must mean that as epidurals became more freely available, women having difficult OP labors were more likely to opt for one. Epidurals were the result, not the cause, of persistent OP. On the other hand, we have some corroborating evidence for their guilt. For one thing, back pain is thought to be a major reason why women with OP babies are more likely to want epidurals, but it turns out that back pain isn’t unique to OP. Serial sonograms reveal that virtually identical percentages of women laboring with an OA baby report back pain (Lieberman, 2005). For another, three of the five studies took into account other factors associated with difficult labor such as labor induction, labor augmentation, and birth weight and still found that epidurals were an independent risk factor for persistent OP (Cheng, 2006; Lieberman, 2005; Sizer, 2000).

Nevertheless, evidence from observational studies isn’t strong enough to close the case. As I noted, observational studies can determine association but not causation. In addition, investigators may not be able to identify all the confounding and correlating factors that affect outcomes. For a more definitive answer, we need experimental studies. This brings us to randomized controlled trials (RCTs), in which participants are randomly allocated to one form of treatment or the other, and to meta-analysis of RCTs, in which statistical techniques are used to pool data from more than one trial.

The Cochrane systematic review of epidural versus no epidural in labor pools data from four RCTs (673 women overall) that reported on persistent OP (Anim-Somuah, 2011). Five more women per 100 assigned to the epidural group had a persistent OP baby, but meta-analysis found that the difference just missed achieving statistical significance. The risk ratio was 1.4, meaning a 40% increased risk of persistent OP in women assigned to the epidural group compared with women assigned to the no-epidural group, but the 95% confidence interval ranged from 1.0 to 2.0, meaning a 95% probability that the true value lies between no increase (ratio of 1:1) and double the risk (2.0). However, a problem with the RCTs of epidural versus no epidural is that substantial percentages of women assigned to the no-epidural group actually had epidurals, but, as is prescribed in RCT data analysis, they were kept in their original group. In two of the four trials (204 women), though, 10% or less of women assigned to the no-epidural group had epidurals. If we calculate the excess rate of persistent OP in these two trials, we find that the gap widens to 9 more women per 100 with epidurals having a persistent OP baby. We don’t know whether this difference would achieve statistical significance, but the fact that the excess is in the same range as reported in the observational studies (4 to 10 more per 100) gives confidence in its validity.

Patti Ramos Photography

We also have two studies that suggest that the timing of the epidural may matter. One, of 320 women, reports that, after controlling for age, induction of labor, and birth weight, initiating an epidural at fetal station less than zero (above the ischial spines) resulted in 16 more women having a persistent OP or occiput transverse (OT) baby compared with initiation at 0 station or greater (at or lower than the ischial spines), an excess that rose to 20 more per 100 in first time mothers (Robinson, 1996). The other study analyzed outcomes in 500 first-time mothers according to whether an epidural was administered early (at or before 5 cm dilation), late (after 5 cm dilation), or not at all (Thorp, 1991). Seventeen more women per 100 in the early group had a persistent OP or OT baby compared with women in the late-epidural group, and 12 more had a persistent OP or OT baby compared with the no-epidural group, but rates were similar in women in the late and no epidural groups.

Taken all together, we may not have absolute proof of epidural culpability in predisposing to OP, but if I were on the jury, I would vote them “guilty as charged.”

Take home: Even without certainty, the precautionary principle dictates recommending to women desiring an epidural that they use other measures to cope with labor pain until they enter active labor and until it seems clear that positioning and activities are not putting a slow labor on track.

What do you tell your clients, students and patients about the impact on fetal positioning in labor and birth?  Will having this information change what you say?  Let us know in the comments section.

References

Anim-Somuah, M., Smyth, R. M., & Jones, L. (2011). Epidural versus non-epidural or no analgesia in labour. Cochrane Database of Systematic Reviews(12), CD000331.

Cheng, Y. W., Shaffer, B. L., & Caughey, A. B. (2006). Associated factors and outcomes of persistent occiput posterior position: A retrospective cohort study from 1976 to 2001. Journal of Maternal Fetal and Neonatal Medicine, 19(9), 563-568.

Fitzpatrick, M., McQuillan, K., & O’Herlihy, C. (2001). Influence of persistent occiput posterior position on delivery outcome. Obstetrics and Gynecology, 98(6), 1027-1031.

Lieberman, E., Davidson, K., Lee-Parritz, A., & Shearer, E. (2005). Changes in fetal position during labor and their association with epidural analgesia. Obstetrics and Gynecology, 105(5 Pt 1), 974-982.

Ponkey, S. E., Cohen, A. P., Heffner, L. J., & Lieberman, E. (2003). Persistent fetal occiput posterior position: obstetric outcomes. Obstetrics and Gynecology, 101(5 Pt 1), 915-920. 

Robinson, C. A., Macones, G. A., Roth, N. W., & Morgan, M. A. (1996). Does station of the fetal head at epidural placement affect the position of the fetal vertex at delivery? American Journal of Obstetrics and Gynecology, 175(4 Pt 1), 991-994.

Sizer, A. R., & Nirmal, D. M. (2000). Occipitoposterior position: associated factors and obstetric outcome in nulliparas. Obstetrics and Gynecology, 96(5 Pt 1), 749-752.

Thorp, J. A., Eckert, L. O., Ang, M. S., Johnston, D. A., Peaceman, A. M., & Parisi, V. M. (1991). Epidural analgesia and cesarean section for dystocia: risk factors in nulliparas. American Journal of Perinatology, 8(6), 402-410.

Childbirth Education, Epidural Analgesia, Evidence Based Medicine, Guest Posts, informed Consent, Medical Interventions, Pain Management, Research , , , , , , ,