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Attitudes Drive Everything: With providers and women fearful of birth and operating in an evidence vacuum, the results are not wonderful

June 22nd, 2011 by avatar

Research by our UBC affiliated Child and Family Research Institute has revealed that the increase in Caesarean section rates across Canada may be largely due to the attitudes and beliefs of the obstetricians and other providers towards birth technology and Caesarean sections. 81 per cent of obstetricians 40 years or younger were women versus 40 per cent over 40 years of age. The attitudes and beliefs vary by age of practitioner. In contrast to their older counterparts, younger obstetricians were significantly more likely to favour a hospital based medically managed birth and the routine use of epidural analgesia in normal births. They were less likely to support vaginal birth after Caesarean section or to appreciate the importance of mothers’ role in their own birth. They also appeared to be more “fearful” of the consequences of vaginal birth, particularly in relation to urinary incontinence and sexual problems and more likely to select Caesarean section for their own births. Older obstetricians, the majority of which are male, were more supportive of a woman-centered model of care, more positive about birth plans, and were more likely to see vaginal birth as more empowering to the mother than Caesarean section. (1) The finding that younger obstetricians, who are mostly women, appeared to have less appreciation of the role of a woman in her own birth than older usually male obstetricians is counterintuitive and requires further study. These attitudes appear related to experiences in training rather than to gender, as younger male obstetricians have attitudes similar to their female counterparts. Without addressing the educational system, attitudes will be difficult to change.

Another study by our group (2) found that clients of midwives, were more supportive of women’s roles in their own deliveries and less likely to support the use of technology, compared to physicians’ patients. It should be noted that regardless of the type of care provider, many women reported inadequate knowledge of common procedures. Women’s lack of knowledge about procedures such as epidural analgesia, Caesarean section and episiotomy, raise concerns about prenatal education and prenatal care. Attendance at prenatal education classes is decreasing in all regions of Canada and most pregnant women indicated they use health care providers, books and the internet as their main sources of prenatal information. (2) When combined with evidence on the nature of obstetrical power and control, and research showing that many providers are not evidence-based in their views, (3) this suggests that even a woman with strong values and beliefs could find it challenging to assert her choices in the professionally controlled process of birth. Women, especially first time mothers, who do not have evidence-based knowledge, are likely to be particularly sensitive to negative attitudes toward birth procedures and processes, from providers and other sources.

A third study from our group found that family doctors who do not provide intrapartum care have more negative attitudes toward birth and are less evidence-based about what is going on in the delivery suite. (4) Since this group provides more than 50% of the antenatal care in Canada, efforts to keep them up to date need to be implemented, lest they transmit their negative attitudes to women before transfer for birth care to other providers.

Finally as Caesarean section rates are steeply rising, with BC having the highest rates in Canada, and for the first time, maternal mortality and morbidity rates are increasing in the US and Canada due to overuse of Caesarean sections, (2)it is time for the public to realize that Caesarean section, while life-saving when needed, is not as safe a vaginal birth (5-7), and it is not just another way to have a baby.

And lest you think that this is a Canadian problem, the educational and training systems for medical students and obstetrical and family practice residents is the same both sides of the border. Educational, rather than health care models, trumps evidence. We are teaching directly and indirectly that childbirth is just an opportunity for things to go wrong. Medical students, obstetrical and family practice residents rarely see normal birth, and they are not exposed to midwives in hospital or at home births. It is going to take a revolution driven by women to change this, as practitioners are not going to change very soon. To the barricades!

Posted by:  Michael Klein, MD

[Editor’s note:  As an example of the debate Dr. Klein introduces here, proposing that Caesarean birth is not just another way to have a baby, check out this article in today’s edition of The Sun, questioning whether or not Caesarean birth is “normal.”]




1.         Klein M, Liston R, Fraser W, Baradaran N, Hearps S, Tomkinson J, et al. The attitudes of the new generation of Canadian obstetricians: how do they differ from their predecessors. Birth. 2011.

2.         Klein M, Kaczorowsk J, Hearps S, Tomkinson J, Baradaran N, Hall W, et al. Birth technology and maternal roles in birth: knowledge and attitudes of Canadian women approaching childbirth for the first time. JOGC. 2011(June):598-608.

3.         Klein M, Kaczorowski J, Hall W, Fraser W, Liston R, Eftekhary S, et al. The Attitudes of Canadian Maternity Care Practitioners Towards Labour and Birth: Many Differences But Important Similarities. Journal of Obstetrics & Gynaecology Canada: JOGC. 2009;31(9 ):827-40.

4.         Klein M, Kaczorowski J, Tomkinson J, Hearps S, Baradaran N, Brant R. Family physicians who provide intrapartum care and those that do not: very different ways of viewing childbirth. Can Fam Phys. 2011 57(4):e139-e47.

5.         SOGC. Joint Policy Statement on Normal Childbirth. JOGC. 2008;221(December):1163-5.

6.         SOGC. C-sections on demand—: SOGC’s position. [Press Release].  Society of Obstetricians and GynecologistsMar 10, 2004.

7.         Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS, et al. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. Cmaj. 2007 February 13, 2007;176(4):455-60.


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

March 4th, 2011 by avatar

[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

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

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

February 25th, 2011 by avatar
This post is the second in a series by Dr. Michael Klein.  You can find the first installment of this series here.

Research into the consequences of epidural use
Whether the benefits of epidural analgesia outweigh the potential risks has been the subject of many controversies over recent decades. In my department we have studied these controversies extensively. On a regular basis we looked at our own performance in caring for laboring women. The Department of Family Practice at British Columbia Women’s Hospital in Canada (familiarly known as ‘BC Women’s)’is made up of over 100 family doctors, who all attend births. BC Women’s is the largest maternity hospital in Canada, with more than 7,000 births per year, and family doctors are responsible for almost half of these births, despite the hospital also being the tertiary care referral centre for the province. This makes us the largest group of family doctors attending births in Canada.

We knew from the literature that epidural analgesia use early in labour, before the fetus was well down in the pelvis, could cause malpositioning (occiput posterior or transverse) (7) due to extension of the fetal head. If the fetal head is extended, it cannot rotate or descend. We found that physicians who ordered epidurals frequently and early in labour had more patients with malpositioned fetuses.(8) They also had more patients who received greater amounts of synthetic oxytocin augmentation of labour. They had fewer spontaneous births and more cesarean sections than those in the department who used epidurals less often. Also, surprisingly, high epidural rates were associated with increased numbers of newborns with low 5-minute Apgar scores and more babies admitted to the newborn intensive care unit.

We found that physicians with mean epidural rates under 40% for women having their first baby, had cesarean section rates of about 10%. In contrast, those family doctors with mean epidural rates of 71-100% had cesarean section rates of 23.4%, the others having rates between the two extremes. The women cared for by the three groups were similar. Thus it appeared that only physician practice difference could have accounted for such large differences in outcome. Interestingly, the caesarean rates of women who were having their second or more births were unaffected by the way in which their doctors prescribed epidurals.

Our departmental experience was similar to results from an observational study in which we compared outcomes at a nearby community hospital with our tertiary care centre. (9) In the community care setting, mean epidural analgesia rates were 15.4% compared with 67.2% in the tertiary care center, for comparable women. The odds of having a cesarean section were 3.4 times greater at the tertiary care centre than in the community hospital. The increased and earlier use of epidural analgesia in the tertiary care setting almost completely explained this difference. The community hospital setting encouraged the use of other non-epidural pain coping techniques, resulting in later epidural placements compared to those in the tertiary hospital setting. We were also interested to note that those physicians who ordered epidurals less often actually spent more time with their patients, even though on average their patients spent less time in hospital. The time they spent with their patients involved more intimate, hands-on, supportive care.

It is because of these studies that we had trouble accepting the results of the 2004 Cochrane meta-analysis that concluded that epidural analgesia did not raise the cesarean section rate.(10) This conclusion was the same in the most recent Cochrane meta-analysis,(11) this new one deeply flawed by the inclusion of many studies of women who suffered from complex medical conditions, and many studies that randomized women late, particularly since conventional practice is to use epidurals earlier. Clearly, any meta-analysis is only as good as the individual studies included—illustrating the well-known principle: garbage in, garbage out.

Epidural Analgesia has transformed birth:
In fact, it appeared to us that the increasing use of epidural analgesia was transforming birth. This observation was confirmed by a report from the Canadian Institute for Hospital Information, which indicated that 4 in 5 Canadian women received one or more major obstetrical interventions, with epidurals high on the list at rates of 40-50% of births in various Canadian settings. (12)

We decided to look more closely at earlier Cochrane (10) individual studies that made up the meta-analysis addressing the effect of epidural analgesia on c-section rates. These studies revealed that, epidural analgesia increased the length of the first stage of labour by 4.3 hours. Similarly, the second stage of labour was increase by 1.4 hours. Malpositions were found in 15% of cases where epidurals were used but in only 7% of cases where narcotics were used. Synthetic oxytocin augmentation of labour was found in 52% of women with epidurals and in 7% of women who had narcotic analgesia. Instrumentation (forceps and vacuum) was found in 27% of epidural cases compared with a rate of 16% among women not getting an epidural. Maternal fever was dramatically higher in the epidural versus narcotic analgesia groups—24% and 6%, respectively.

Maternal fever is a common side effect of epidural analgesia because it interferes with the sympathetic and parasympathetic nervous system balance, altering the body’s normal methods to eliminate heat. And since it is hard to know if the fever is due to infection or an epidural effect, a septic work-up is usually carried out following birth on both the mother and baby, including blood and possibly cerebral spinal fluid tests, along with frequent placement on prophylactic antibiotics. Additionally, increased maternal temperature can cause a rapid fetal heart rate and, thus, prompt a caesarean section due to concerns for fetal well-being.

Additionally, several studies have shown that perineal trauma increased two-fold in women who had had an epidural, due in part to an increased use of forceps and vacuum, which in and of themselves are associated with more perineal trauma (with or without epidurals).(13, 14)

Given all the other increases in intervention rates, we found it hard to understand why cesarean section rates were not also higher in the Cochrane meta-analysis. In fact, when we separated out the studies that made up the 2004 Cochrane meta-analysis, we found that, in those studies that showed no difference in cesarean section rates, epidurals had been administered after labour was well established (in the active phase at 4-5cm or more of cervical dilation). In the studies where epidurals were given early on in labour, before the active phase (before 4-5cm of cervical dilation)—the cesarean section rate increased more than 2.5 times. (15, 16)

Inadvertently, the Cochrane meta-analysis of epidural analgesia has caused more frequent use of epidurals, resulting in more continuous electronic fetal monitoring, immobility of the labouring woman, increased instrumentation and perineal trauma, and an increase in the cesarean section rate. Because more women will have received a cesarean section, another consequence will be an increase in problems in subsequent pregnancies relating to placentation issues (previa, accrete, percreta, abruption), infertility, and ectopic pregnancy.(17-20) In most maternity care settings, these down-stream consequences (‘collateral damage’) from epidural use are not discussed.

Dr. Klein’s final post next week will take a look at the realities of how epidural analgesia has “transformed birth.” All references for this series of posts can be found here: References _ michael klein post 





Posted 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

[MK1]Mixing issues here


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

February 3rd, 2011 by avatar

This is the beginning of a three-part series of posts from family practice physician, pediatrician , neonatologist and Senior Scientist for the Centre for Developmental Neuroscience and Child Health and the Family Research Institute, Dr. Michael Klein, who will share this thoughts and analysis with us regarding epidural analgesia…

A short history of epidural analgesia
It was not until the 1960s and 1970s that epidural analgesia became widely available. Prior to that, anaesthesia services dedicated to the provision of epidural analgesia did not exist. By the 1990s, obstetrical anaesthesia services dedicated to maternity care became common in developed countries.

Prior to the ready availability of epidural analgesia in labour and delivery departments, maternity nurses used their skills to reassure, massage, breathe with the woman through contractions, and employ a range of other methods to handle labour pain. But today, the shortage of staff and the institutional demands on nurses make these skills relatively unavailable. In addition, the education of nurses has taken a more technical turn; the ‘old-fashioned’ skills of hands-on nursing has been replaced, in many educational programs, by teaching technical skills related equipment and medical interventions.

It became clear that to make epidural analgesia reliably available, a dedicated anaesthetic staff had to develop. Once such staffs were in place, there was great pressure to keep them busy. After epidurals became more available, a debate ensued, and goes on to this day, about whether withholding an epidural was interfering with a woman’s autonomy. This discussion did not seem to take into consideration that women might not select an epidural if they knew more precisely how long severe pain would last, or if they understood the benefits and problems associated with epidural use, or if staff were trained in a variety of other effective techniques to assist with the pain of labour. In fact, many women are directly or indirectly pressured into accepting epidurals.

The implications of epidural use
Although it first seemed that epidural analgesia freed up nurses to care for more than one woman at a time, in fact, it soon became clear that the labour and delivery nurse’s time was consumed by the technical requirements of safely managing the epidural and the rest of the technical requirements of her job, leaving little time for hands-on nursing support.(1) A woman who has an epidural requires an intravenous line and continuous electronic fetal monitoring to measure both the fetal heartbeat and the uterine contraction pattern. Because labour usually slows after an epidural, the woman typically requires synthetic oxytocin (Pitocin) augmentation to replace her natural oxytocin production, which is inhibited by the epidural itself. Pitocin can cause painful and very strong contractions: therefore its use requires detailed charting and monitoring for the potential complications of the epidural.

Usually after the introduction of an epidural, a woman has to remain in bed because she cannot feel her legs and she is attached to many wires and lines, so this limits her ability to walk or change position. ‘Walking epidurals’ and telemetry are available only in rare settings and by particular anaesthesiologists. Tethered to intravenous lines and other lines (e.g. urinary catheter, blood pressure cuff,  fetal monitor and the tocometer) and unable to walk, it is almost impossible for the woman to use gravity and different positions to help progress her labour.

The development of new pain management techniques
Prior to the availability of epidural analgesia, the childbirth education movement utilized a variety of techniques that were physiologically and psychologically helpful to reduce pain, such as breathing and imagery. These methods began to take hold in the culture in the 1950s and 1960s but today are less prominent in many childbirth education classes. Some classes are more focused on teaching women compliance with particular hospital technological methods and approaches, routines and policies, rather than on teaching women coping skills.

In the late 1970s and early 1980s, the first studies appeared, showing the value of continuous emotional and physical support by a caring, trained and knowledgeable woman, whose responsibility was to focus solely on the labouring woman rather than on the institution or equipment – the doula. Backed by randomized studies,(2-4) it has become apparent that this emotional and physical continuous supportfrom a doula gives a woman more confidence and ability to work with her labour. All studies to date have demonstrated that hospital-based nurses cannot function as doulas,(5, 6) even if those nurses are midwifery-trained. It is not the fact of being either a midwife or a nurse that matters, but the fact that when these care providers are employed by the hospital, their primary allegiance is to the institution, and they are professionally responsible for the conduct of the labour and the safety of both mother and fetus. A doula who is employed by the woman is responsible only to her. Autonomous midwives in the Canadian context are strongly supportive of doulas, with whom they frequently work in collaboration.

Pain moderation by transcutaneous nerve stimulation (TNS) or intradermal water injections can be very helpful, especially in the earlier stages of labour. Other non-pharmacological methods like water baths or showers or movement, including the use of birth balls, are also helpful for many women who find that partial pain relief is sufficient to help them through contractions. Doula care provides a complementary approach which can reduce the need for an epidural or delay epidural usage until the active phase of labour, when some of the negative effects of epidural analgesia are reduced. In particular, during her labour, doula care and non-pharmacological approaches allow the mother more opportunity to produce her own oxytocin. Natural oxytocin has some important effects: it is the anti-stress hormone, and helps contractions to be more productive; it is also the ‘love hormone’ that later goes on to enhance the bonding process following the baby’s birth—an effect suppressed by synthetic oxytocin, little of which enters the brain of either mother or fetus.

Is epidural analgesia the best form of pain relief?
Epidural analgesia is a very effective form of pain relief, meaning that compared to a variety of other pharmacological and non-pharmacological methods, it provides generally consistent pain reduction. If there were no problems associated with epidural analgesia, almost everybody would want it. Unfortunately, though, associated with its use there are various undesieable effects, including:

  • longer first stage labours
  • longer second stage labours
  • increased incidence of maternal fever directly caused by the epidural, which often leads to the use of antibiotics in both the labouring woman and her newborn
  • increased rates of operative vaginal delivery (forceps and vacuum)
  • increased perineal trauma with and without instrumental births – including severe tears into the rectum (3rd and 4th degree tears).
  • a variety of complications such as a placement of an epidural too high on the spine (leading to breathing problems).
  • failure of the epidural to provide any pain relief, or insufficient pain relief—requiring the continued use of other methods of pain relief
  • increased need for a bladder catheter
  • maternal hypotension leading to worrying fetal heart rate changes
  • an increase in the likelihood of the need for a cesarean section – this last complication being the subject of great debate, which will be discussed further

Of course, some of these problems may occur whether the epidural was or was not truly needed. And when an epidural is truly needed for pain relief or to solve a specific problem, it can dramatically change a situation for the better and can improve outcome. It is only when epidurals are used routinely, and especially very early in labour that these complications are more likely to occur.

Dr. Klein’s next post will take a look at the research on epidurals and discuss the risks and benefits of this pain relief technology.
All references for this post series can be found here: References _ michael klein post.

Posted 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

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

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