Archive for the ‘Epidural Analgesia’ Category

Epidurals: Do They or Don’t They Increase Cesareans?

January 27th, 2015 by avatar

By Henci Goer

In October, Author Henci Goer wrote an article for Science & Sensibility, Epidural Anesthesia: To Delay or Not To Delay – That is the Question – examining the impact of the timing of an epidural on labor and birth.  Today Henci looks at some new research, Epidural analgesia in labour and risk of caesarean delivery which seeks to determine whether receiving an epidural at all impacts the likelihood of a cesarean delivery.  Lamaze International has a great infographic on epidurals that you also may find very helpful. – Sharon Muza, Community Manager, Science & Sensibility.

© J. Wasikowski, provided by Birthtastic

© J. Wasikowski, provided by Birthtastic

Let’s start with a bit of background for those of you who didn’t personally live through the early controversy over whether epidurals increased the cesarean rate. As epidurals began to achieve popularity in the late 1970s and 1980s, one researcher sounded the alarm when he and his group published a study of 714 first-time mothers showing that even after excluding women with big babies and women whose labor pattern was abnormal prior to having an epidural, epidurals remained a potent factor in cesarean rates for delayed progress (Thorp 1989). Everyone pooh-poohed his finding on grounds that observational studies can’t truly determine whether epidurals lead to more cesareans or women experiencing more prolonged, painful labors, and therefore at higher risk for cesarean, were more likely to want epidurals. The “chicken versus egg” question, they argued, couldn’t be resolved without a randomized controlled trial (RCT), and it wasn’t likely that women would agree to be assigned by chance to have an epidural or not. In point of fact, that same year saw publication of a small Danish RCT (107 women, 104 of them first-time mothers) (Philipsen 1989). It reported that having an epidural nearly tripled the cesarean rate (16% vs. 6%) for “cephalopelvic disproportion” despite no clinical evidence of CPD being a requirement for inclusion. The investigators ignored this, however, concluding only that instrumental vaginal delivery rates were similar, and epidurals provided better pain relief. In any case, the anesthetic dose was much higher than was already becoming the norm, so it could be reasonably argued that the trial’s findings wouldn’t apply to modern-day practice.

Thorp, meanwhile, took up the RCT challenge. He and his colleagues carried out an epidural versus no epidural trial in 93 first-time mothers and found that epidurals did, in fact, lead to cesareans (25% vs. 2%), not vice versa (Thorp 1993). That bit of unwelcome news precipitated a stampede to perform more RCTs, and when enough of those had accumulated, to a series of systematic reviews pooling their data (meta-analysis), of which the Cochrane review, Anim-Somuah et al. (2011), is the latest. These reached the more comfortable conclusion that epidurals didn’t increase likelihood of cesarean, and pro-epiduralists breathed a collective sigh of relief and went back, if they had ever stopped, to unreservedly recommending epidurals. (This rather sweeps under the rug the other problems epidurals can cause, but that’s a topic for another day.)

Weaknesses of the “Epidural” vs. “No Epidural” Trials


By User:Ravedave (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html)

The finding that epidurals don’t increase cesareans is puzzling because they increase likelihood of factors associated with them (Anim-Somuah 2011). For one thing, they increase use of oxytocin to augment labor, which implies they slow labor. For another, more women run fevers, and it stands to reason that a woman progressing slowly who starts running a fever is a likely candidate for cesarean. For a third, the difference in fetal malposition (occiput posterior) rates at delivery comes close to achieving statistical significance, meaning the difference is unlikely to be due to chance. Persistent OP is strongly associated with cesarean delivery (Cheng 2006; Fitzpatrick 2001; Phipps 2014; Ponkey 2003; Senecal 2005; Sizer 2000). Epidurals even increase cesareans for fetal distress by 40%, although the absolute difference didn’t amount to much (1 more per 100 women). Could a difference exist and meta-analysis of RCTs fail to detect it?

A string of well-conducted observational studies over the years have suggested that they could (Eriksen 2011; Kjaergaard 2008; Lieberman 1996; Nguyen 2010), the most recent of which is a very large, very convincing study published last fall (Bannister-Tyrrell 2014). Its authors point out, as have others before them, the weaknesses of the RCTs, weaknesses serious enough to nullify their results or make them inapplicable to typical community practice (external validity).

To begin with, in most trials, substantial percentages of women allocated to the non-epidural group ended up having epidurals, and some women allocated to the epidural group ended up not having one. Since RCTs analyze results according to group assignment (to do otherwise would negate the point of random assignment, which is to avoid bias), not what actually happened, this diminishes differences between groups. In addition, trials were mostly confined to women with no medical or obstetric complications who were treated according to strict protocols for labor management and indications for cesarean delivery. Neither is the case in most hospitals. To these I would add that many trials lumped together first-time mothers and women with prior births when reporting outcomes. First-time mothers are much more susceptible to factors that impede progress, so including women with prior vaginal births can make it appear that epidurals are less problematic for first-time mothers than they really are. In addition, three of the trials were carried out in a hospital where participants were mostly attended by midwives, and cesarean rates were much lower than is common for women attended by obstetricians.

All of this means that any null results in meta-analyses of the trials can be taken with a grain of salt, any findings of significant differences probably represent a minimal value, and first-time moms may be harder hit than appears. To cite one example, Anim-Somuah (2011) reported that 5 more women per 100 having epidurals had a malpositioned baby at delivery (18% vs. 13%) in the 4 trials reporting this outcome, a difference, as I said, that just missed achieving statistical significance. But when I confined results to the two trials in first-time mothers alone in which 10% or fewer of the women in the “no-epidural” group had an epidural, the gap widened to 9 more per 100 (11% vs. 2%).

Summary of the Bannister-Tyrrell (2014) Analysis

Bannister-Tyrrell and colleagues (2014) drew their population from a database of 210,700 Australian women with no prior cesareans who were laboring at term with a singleton, head-down baby. A strength of the database was that, unlike most, it distinguished epidurals for labor from epidurals for delivery. Using a long list of factors, investigators constructed a propensity score for how likely a woman was to have an epidural, matched women according to their score, and compared results according to whether women with the same score had or didn’t have an epidural. Matched controls were found for 52,600 women who had an epidural and were found across the full range of propensity scores. Women having epidurals were 2.5 times more likely to have a cesarean (20% vs. 8%), or put another way, 12 more women per 100 having epidurals had a cesarean (absolute excess), which amounts to 1 additional cesarean for every 8.5 women having an epidural (number needed to harm). Among first-time mothers, women having epidurals were 2.4 times more likely to have a cesarean. Study authors didn’t provide cesarean rates for this subgroup, but the raw cesarean rates overall were 18% in first-time mothers versus 2% in women with prior births, so the effect on this more vulnerable population could be dire.

But there’s still more. Investigators further adjusted for confounding factors not captured in their database. These included differences in health-care settings (same state but not same city), care provider (women without epidurals are more likely to be attended by midwives), and for confounding interventions more likely with epidurals (continuous fetal monitoring). Relative risk of cesarean with an epidural remained at 2.5. Investigators then adjusted for the association between occiput posterior baby and cesarean by setting estimates of the risk ratio to exceed the strongest associations reported in the literature, and they assumed that the prevalence of severe labor pain was 3 to 4 times higher in women having epidurals. Factoring these into their statistical analysis reduced the risk ratio, but women having epidurals still were 50% more likely to have a cesarean. This means that with a baseline cesarean rate of 8% in women without an epidural, 12% of women with an epidural will have one or 4 more women per 100 or 1 more cesarean for every 25 women.

The Take-Home

At the very least we cannot assure women with confidence that epidurals don’t increase the likelihood of cesarean. For this reason and because of their numerous other drawbacks and considering that comfort measures and other strategies have been shown to be both effective for most women and free of adverse effects (Declercq 2006; Jones 2012), women may want to make epidurals Plan B rather than Plan A. That being said, whatever their choice, women can minimize their chance of cesarean—with or without an epidural—by choosing a midwife or doctor whose policies and practices promote spontaneous vaginal birth http://www.lamaze.org/HealthyBirthPractices.


Anim-Somuah, M., Smyth, R. M., & Jones, L. (2011). Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev(12), CD000331. doi: 10.1002/14651858.CD000331.pub3 http://www.ncbi.nlm.nih.gov/pubmed/22161362

Bannister-Tyrrell, M., Ford, J. B., Morris, J. M., & Roberts, C. L. (2014). Epidural analgesia in labour and risk of caesarean delivery. Paediatr Perinat Epidemiol, 28(5), 400-411. http://www.ncbi.nlm.nih.gov/pubmed/25040829

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. J Matern Fetal Neonatal Med, 19(9), 563-568. http://www.ncbi.nlm.nih.gov/pubmed/16966125?dopt=Citation

Declercq, E., Sakala, C., Corry, M. P., & Applebaum, S. (2006). Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection. http://childbirthconnection.org/pdfs/LTMII_report.pdf

Eriksen, L. M., Nohr, E. A., & Kjaergaard, H. (2011). Mode of delivery after epidural analgesia in a cohort of low-risk nulliparas. Birth, 38(4), 317-326. http://www.ncbi.nlm.nih.gov/pubmed/22112332

Fitzpatrick, M., McQuillan, K., & O’Herlihy, C. (2001). Influence of persistent occiput posterior position on delivery outcome. Obstet Gynecol, 98(6), 1027-1031. http://www.ncbi.nlm.nih.gov/pubmed/11755548?dopt=Citation

Jones, L., Othman, M., Dowswell, T., Alfirevic, Z., Gates, S., Newburn, M., . . . Neilson, J. P. (2012). Pain management for women in labour: an overview of systematic reviews. Cochrane Database Syst Rev, 3, CD009234. http://www.ncbi.nlm.nih.gov/pubmed/22419342

Kjaergaard, H., Olsen, J., Ottesen, B., Nyberg, P., & Dykes, A. K. (2008). Obstetric risk indicators for labour dystocia in nulliparous women: a multi-centre cohort study. BMC Pregnancy Childbirth, 8, 45. http://www.ncbi.nlm.nih.gov/pubmed/18837972?dopt=Citation

Lieberman, E., Lang, J. M., Cohen, A., D’Agostino, R., Jr., Datta, S., & Frigoletto, F. D., Jr. (1996). Association of epidural analgesia with cesarean delivery in nulliparas. Obstet Gynecol, 88(6), 993-1000. http://www.ncbi.nlm.nih.gov/pubmed/8942841

Nguyen, U. S., Rothman, K. J., Demissie, S., Jackson, D. J., Lang, J. M., & Ecker, J. L. (2010). Epidural analgesia and risks of cesarean and operative vaginal deliveries in nulliparous and multiparous women. Matern Child Health J, 14(5), 705-712. http://www.ncbi.nlm.nih.gov/pubmed/19760498?dopt=Citation

Philipsen, T., & Jensen, N. H. (1989). Epidural block or parenteral pethidine as analgesic in labour; a randomized study concerning progress in labour and instrumental deliveries. Eur J Obstet Gynecol Reprod Biol, 30(1), 27-33. http://www.ncbi.nlm.nih.gov/pubmed/2924990

Phipps, H., Hyett, J. A., Graham, K., Carseldine, W. J., Tooher, J., & de Vries, B. (2014). Is there an association between sonographically determined occipito-transverse position in the second stage of labor and operative delivery? Acta Obstet Gynecol Scand, 93(10), 1018-1024. http://www.ncbi.nlm.nih.gov/pubmed/25060716

Ponkey, S. E., Cohen, A. P., Heffner, L. J., & Lieberman, E. (2003). Persistent fetal occiput posterior position: obstetric outcomes. Obstet Gynecol, 101(5 Pt 1), 915-920. http://www.ncbi.nlm.nih.gov/pubmed/12738150?dopt=Citation

Senecal, J., Xiong, X., Fraser, W. D., & Pushing Early Or Pushing Late with Epidural study, group. (2005). Effect of fetal position on second-stage duration and labor outcome. Obstet Gynecol, 105(4), 763-772. http://www.ncbi.nlm.nih.gov/pubmed/15802403

Sizer, A. R., & Nirmal, D. M. (2000). Occipitoposterior position: associated factors and obstetric outcome in nulliparas. Obstet Gynecol, 96(5 Pt 1), 749-752. http://www.ncbi.nlm.nih.gov/pubmed/11042312?dopt=Citation

Thorp, J. A., Hu, D. H., Albin, R. M., McNitt, J., Meyer, B. A., Cohen, G. R., & Yeast, J. D. (1993). The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial. Am J Obstet Gynecol, 169(4), 851-858. http://www.ncbi.nlm.nih.gov/pubmed/8238138?dopt=Citation

Thorp, J. A., Parisi, V. M., Boylan, P. C., & Johnston, D. A. (1989). The effect of continuous epidural analgesia on cesarean section for dystocia in nulliparous women. Am J Obstet Gynecol, 161(3), 670-675. http://www.ncbi.nlm.nih.gov/pubmed/2782350

About Henci Goer

Henci Goer

Henci Goer

Henci Goer, award-winning medical writer and internationally known speaker, is the author of The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth: The Case for a Physiologic Approach She is the winner of the American College of Nurse-Midwives “Best Book of the Year” award. An independent scholar, she is an acknowledged expert on evidence-based maternity care.  


Cesarean Birth, Childbirth Education, Epidural Analgesia, Guest Posts, Healthy Birth Practices, Medical Interventions, New Research, Pain Management, Research , , , , , , ,

Epidural Analgesia: To Delay or Not to Delay, That Is the Question

October 23rd, 2014 by avatar

By Henci Goer

Unless you have been “off the grid” on a solitary trek, surely you have read and heard the recent flurry of discussion surrounding the just released study making the claim that the timing of when a woman receives an epidural (“early” or “late” in labor) made no difference in the rate of cesarean delivery.  Your students and clients may have been asking questions and wondering if the information is accurate.  Award winning author and occasional Science & Sensibility contributor Henci Goer reviews the 9 studies that made up the Cochrane systematic review: Early versus late initiation of epidural analgesia for labour to determine what they actually said.  Read her review here and share if you agree with all the spin in the media about this new research review. Additionally, head on over to the professional and parent Lamaze International sites to check out the new infographic on epidurals to share with your students and clients.- Sharon Muza, Science & Sensibility Manager. 

Epidural infographic oneArticles have been popping up all over the internet in recent weeks citing a new Cochrane systematic review- Early versus late initiation of epidural analgesia for labour, concluding that epidural analgesia for labor needn’t be delayed because early initiation doesn’t increase the likelihood of cesarean delivery, or, for that matter, instrumental vaginal delivery (Sng 2014). The New York Times ran this piece. Some older studies have found that early initiation appeared to increase likelihood of cesarean (Lieberman 1996; Nageotte 1997; Thorp 1991), which is plausible on theoretical grounds. Labor progress might be more vulnerable to disruption in latent than active phase. Persistent occiput posterior might be more frequent if the woman isn’t moving around, and fetal malposition greatly increases the likelihood of cesarean and instrumental delivery. Which is right? Let’s dig into the review.

The review includes 9 randomized controlled trials of “early” versus “late” initiation of epidural analgesia. Participants in all trials were limited to healthy first-time mothers at term with one head-down baby. Five trials further limited participants to women who began labor spontaneously, three mixed women being induced with women beginning labor spontaneously, and in one, all women were induced. Analgesia protocols varied, but all epidural regimens were of modern, low-dose epidurals. So far, so good.

Examining the individual trials, though, we see a major problem. You would think that the reviewers would have rejected trials that failed to divide participants into distinct groups, one having epidural initiation in early labor and the other in more advanced labor, since the point of the review is to determine whether early or late initiation makes a difference. You would think wrong. Of the nine included trials, six failed to do this.

cc photo bryanrmason http://flickr.com/photos/b-may/397189835

cc photo bryanrmason http://flickr.com/photos/b-may/397189835

The two Chestnut trials (1994a; 1994b) had the same design, differing only in that one was of women who were laboring spontaneously at trial entry and the other included women receiving oxytocin for induction or augmentation. Women were admitted to the trial if they were dilated between 3 and 5 cm. Women in the early group got their epidural immediately while women in the late group could have an epidural only if they were dilated to 5 cm or more. If late-group women were not dilated to 5 cm, they were given systemic opioids and could have a second dose of opioid one hour later. They could have an epidural when they attained 5 cm dilation or regardless of dilation, an hour after the second opioid dose. Let’s see how that worked out.

Among the 149 women in the trial that included women receiving oxytocin (Chestnut 1994b), median dilation in the early group at time of epidural initiation was 3.5 cm, meaning that half the women were dilated more and half less than this amount. The interquartile deviation was 0.5 cm, which means that values were fairly tightly clustered around the median. The authors state, however, that cervical dilation was assessed using 0.5 increments which meant that dilation of 3-4 cm was recorded as 3.5. In other words, women in the early group might have been dilated to as much as 4 cm. The median dilation in the late group was 5.0 cm, again with a 0.5 cm interquartile deviation. Some women in the late group, therefore, were not yet dilated to 5 cm when their epidural began, and, in fact, the authors report that 26 of the 75 women (35%) in the late group were given their epidural after the second dose of opioid but before attaining 5 cm dilation. The small interquartile deviation in the late group tells us that few, if any, women would have been dilated much more than 5 cm. Add in that assessing dilation isn’t exact, so women might have been a bit more or less dilated than they were thought to be, and it becomes clear that the “early” and “late” groups must have overlapped considerably. Furthermore, pretty much all of them were dilated between 3 and 5 cm when they got their epidurals, which means that few of these first-time mothers would have been in active labor, as defined by the new ACOG standards.

Overlap between early and late groups must have been even greater in Chestnut et al.’s (1994a) trial of 334 women laboring spontaneously at trial entry because median dilation in the early group was greater than in the other trial (4 cm, rather than 3.5) while median dilation in the late group was the same (5.0 cm), and interquartile deviation was even tighter in the late group (0.25 cm, rather than 0.5 cm). As before, dilation was measured in 0.5 cm increments, which presumably means that women in the early group dilated to 4-5 cm would have been recorded as “4.5,” thereby qualifying them for the “early” group even though they might have been as much as 5 cm dilated.

Based on my analysis, I would argue that there was no clinically meaningful difference in dilation between early and late groups in either trial.

A second pair of trials, one a mixed trial of spontaneous labor onset and induction and the other all induced, also had the same design in both trials (Wong 2005; Wong 2009). All women were less than 4 cm dilated at first request for pain medication. In the early group, women had an opioid injected intrathecally, i.e. the “spinal” part of a combined spinal-epidural, and an epidural catheter was set. At the second request, an epidural was initiated. In the late group, women were given a systemic opioid. At second request, they were given a second dose of systemic opioid if they hadn’t reached 4 cm dilation and an epidural if they had dilated to 4 cm or more. At third request, they were given an epidural regardless of dilation. Women who had no vaginal exam at second request and were given an epidural were “assumed,” in the authors’ words, to be dilated to at least 4 cm. What were the results?

Wong (2005) included 728 women, some beginning labor spontaneously and some induced. You may already have noticed the flaw in the trials’ design: Wong and colleagues confused the issue by considering intrathecal opioid to be equivalent to epidural anesthetic in the early group, although women didn’t actually receive anesthetic until their second request for pain medication some unknown time later. So far as I know we have no evidence that opiods, spinal or epidural, have any effect on labor progress. As to dilation at the time of epidural initiation, 63% of women in the so-called “early” group were either determined or assumed to be at 4 cm dilation or more while in the late group, some unknown proportion were less than 4 cm dilated either because they got their epidural at third pain medication request regardless of dilation or they were assumed to be at 4 or more cm dilation at second request, but weren’t assessed.

Wong (2009), a study of 806 induced women, was set up the same way but reported data somewhat differently. Early-group women were administered a spinal opioid at a median of 2 cm dilation and an interquartile range of 1.5 to 3 cm, which means that values in the middle 50% of the dataset ranged from 1.5 to 3 cm. We have no information on dilation at the time they received their epidural. The median dilation at which late-group women had their epidural initiated was 4 cm with an interquartile range of 3 to 4 cm, that is, in the middle 50% of the dataset ranged from 3 to 4 cm dilation.

As with the Chestnut trials, dilation at time of epidural initiation in the two Wong trials must have overlapped considerably between groups. And, again, few women in the late epidural group would have been in active labor. The Wong trials, however, muddy the waters even further by considering spinal opioid to be the same thing as epidural anesthetic, and while the authors were careful to use the term “neuraxial analgesia,” the Cochrane reviewers made no such distinction.

This brings us to Parameswara (2012), a trial of 120 women that included both spontaneous onset and induced labors. This trial defined the early group as women less than 2 cm dilated at time of epidural initiation and the late group as women more than 2 cm dilated. That’s all the information they provide on group allocation.

Last of the six, we have Wang (2011), a trial of 60 women in spontaneous labor. All women were given intrathecal anesthetic plus opioid. The early group was started on epidural anesthetic plus opioid 20 minutes later whereas the late group had their epidural initiated when they requested additional pain relief. No information is given on dilation at time of epidural initiation. Not only do we have no idea whether early and late groups differed from one another, women in both groups received neuraxial anesthetic at the same time.

In summary, “garbage in, garbage out.” No conclusions can be drawn about the effect of early versus late epidural administration from these six studies.

The other three studies are a different story. They achieve a reasonable separation between groups. Luxman (1998) studied 60 women with spontaneous labor onset. The early group had a mean, i.e., average, dilation of 2.3 cm with a standard deviation of + or – 0.6 cm while the late group had a mean dilation of 4.5 cm + or – 0.2 cm. Ohel (2006) studied a mixed spontaneous onset and induced group of 449 women. The mean dilation at initiation in the early group was 2.4 cm with a standard deviation of 0.7 cm, and the late group had a mean dilation of 4.6 cm with a standard deviation of 1.1 cm. Wang (2009), the behemoth of the trials, included 12,629 women who began labor spontaneously. The early epidural group had a median dilation of 1.6 cm with an interquartile range of 1.1 to 2.8 and the late group a median of 5.1 cm dilation with an interquartile range of 4.2 to 5.7. Cesarean and instrumental delivery rates were similar between early and late groups in all three trials, so had reviewers included only these three trials, they would still have arrived at the same conclusion: early epidural initiation doesn’t increase likelihood of cesarean and instrumental delivery.

We’re not done, though. Wang (2009) points us to a second, even bigger issue.

The Wang (2009) trial, as did all of the trials, limited participants to healthy first-time mothers with no factors that would predispose them to need a cesarean. The Wang trial further excluded women who didn’t begin labor spontaneously. Nevertheless, the cesarean rate in these ultra-low-risk women was an astonishing 23%. Comparing the trials side-by-side reveals wildly varying cesarean and instrumental vaginal delivery rates in what are essentially homogeneous populations.

© Henci Goer

© Henci Goer

© Henci Goer

© Henci Goer

Comparing the trials uncovers that epidural timing doesn’t matter because any effect will be swamped by the much stronger effect of practice variation.

Analysis of the trials teaches us two lessons: First, systematic reviews can’t always be taken at face value because results depend on the beliefs and biases that the reviewers bring to the table. In this case, they blinded reviewers from seeing that two-thirds of the trials they included weren’t measuring two groups of women, one in early- and one in active-phase labor. Second, practice variation can be an unacknowledged and potent confounding factor for any outcome that depends on care provider judgment.


So what’s our take home? Women need to know that with a judicious care provider who strives for spontaneous vaginal birth whenever possible, early epidural administration won’t increase odds of cesarean or instrumental delivery. With an injudicious one, late initiation won’t decrease them. That being said, there are other reasons to delay an epidural. Maternal fever is associated with epidural duration. Running a fever in a slowly progressing labor could tip the balance toward cesarean delivery as well as have consequences for the baby such as keeping the baby in the nursery for observation, testing for infection, or administering prophylactic IV antibiotics. Then too, a woman just might find she can do very well without one. Epidurals can have adverse effects, some of them serious. Comfort measures, cognitive strategies, and all around good emotionally and physically supportive care don’t. Hospitals, therefore, should make available and encourage use of a wide range of non-pharmacologic alternatives and refrain from routine practices that increase discomfort and hinder women from making use of them. Only then can women truly make a free choice about whether and when to have an epidural.

After reading Henci’s review and the study, what information do you feel is important for women to be aware of regarding epidural use in labor?  What will you say when asked about the study and timing of an epidural?  You may want to reference a previous Science & Sensibility article by Andrea Lythgoe, LCCE, on the use of the peanut ball to promote labor progress when a woman has an epidural. – SM 


Caughey, A. B., Cahill, A. G., Guise, J. M., & Rouse, D. J. (2014). Safe prevention of the primary cesarean delivery. American journal of obstetrics and gynecology210(3), 179-193.

Chestnut, D. H., McGrath, J. M., Vincent, R. D., Jr., Penning, D. H., Choi, W. W., Bates, J. N., & McFarlane, C. (1994a). Does early administration of epidural analgesia affect obstetric outcome in nulliparous women who are in spontaneous labor? Anesthesiology, 80(6), 1201-1208. http://www.ncbi.nlm.nih.gov/pubmed/8010466?dopt=Citation

Chestnut, D. H., Vincent, R. D., Jr., McGrath, J. M., Choi, W. W., & Bates, J. N. (1994b). Does early administration of epidural analgesia affect obstetric outcome in nulliparous women who are receiving intravenous oxytocin? Anesthesiology, 80(6), 1193-1200. http://www.ncbi.nlm.nih.gov/pubmed/8010465?dopt=Citation

Lieberman, E., Lang, J. M., Cohen, A., D’Agostino, R., Jr., Datta, S., & Frigoletto, F. D., Jr. (1996). Association of epidural analgesia with cesarean delivery in nulliparas. Obstet Gynecol, 88(6), 993-1000. http://www.ncbi.nlm.nih.gov/pubmed/8942841

Luxman, D., Wolman, I., Groutz, A., Cohen, J. R., Lottan, M., Pauzner, D., & David, M. P. (1998). The effect of early epidural block administration on the progression and outcome of labor. Int J Obstet Anesth, 7(3), 161-164. http://www.ncbi.nlm.nih.gov/pubmed/15321209?dopt=Citation

Nageotte, M. P., Larson, D., Rumney, P. J., Sidhu, M., & Hollenbach, K. (1997). Epidural analgesia compared with combined spinal-epidural analgesia during labor in nulliparous women. N Engl J Med, 337(24), 1715-1719. http://www.ncbi.nlm.nih.gov/pubmed/9392696?dopt=Citation

Ohel, G., Gonen, R., Vaida, S., Barak, S., & Gaitini, L. (2006). Early versus late initiation of epidural analgesia in labor: does it increase the risk of cesarean section? A randomized trial. Am J Obstet Gynecol, 194(3), 600-605. http://www.ncbi.nlm.nih.gov/pubmed/16522386?dopt=Citation

Parameswara, G., Kshama, K., Murthy, H. K., Jalaja, K., Venkat, S. (2012). Early epidural labour analgesia: Does it increase the chances of operative delivery? British Journal of Anaesthesia 108(Suppl 2):ii213–ii214. Note: This is an abstract only so all data from it come from the Cochrane review.

Sng, B. L., Leong, W. L., Zeng, Y., Siddiqui, F. J., Assam, P. N., Lim, Y., . . . Sia, A. T. (2014). Early versus late initiation of epidural analgesia for labour. Cochrane Database Syst Rev, 10, CD007238. doi: 10.1002/14651858.CD007238.pub2 http://www.ncbi.nlm.nih.gov/pubmed/25300169

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. Am J Perinatol, 8(6), 402-410. http://www.ncbi.nlm.nih.gov/pubmed/1814306?dopt=Citation

Wang, F., Shen, X., Guo, X., Peng, Y., & Gu, X. (2009). Epidural analgesia in the latent phase of labor and the risk of cesarean delivery: a five-year randomized controlled trial. Anesthesiology, 111(4), 871-880. http://www.ncbi.nlm.nih.gov/pubmed/19741492?dopt=Citation

Wang, L. Z., Chang, X. Y., Hu, X. X., Tang, B. L., & Xia, F. (2011). The effect on maternal temperature of delaying initiation of the epidural component of combined spinal-epidural analgesia for labor: a pilot study. Int J Obstet Anesth, 20(4), 312-317. http://www.ncbi.nlm.nih.gov/pubmed/21840705

Wong, C. A., McCarthy, R. J., Sullivan, J. T., Scavone, B. M., Gerber, S. E., & Yaghmour, E. A. (2009). Early compared with late neuraxial analgesia in nulliparous labor induction: a randomized controlled trial. Obstet Gynecol, 113(5), 1066-1074. http://www.ncbi.nlm.nih.gov/pubmed/19384122?dopt=Citation

Wong, C. A., Scavone, B. M., Peaceman, A. M., McCarthy, R. J., Sullivan, J. T., Diaz, N. T., . . . Grouper, S. (2005). The risk of cesarean delivery with neuraxial analgesia given early versus late in labor. N Engl J Med, 352(7), 655-665. http://www.ncbi.nlm.nih.gov/pubmed/15716559?dopt=Citation

About Henci Goer

Henci Goer

Henci Goer

Henci Goer, award-winning medical writer and internationally known speaker, is the author of The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth: The Case for a Physiologic Approach She is the winner of the American College of Nurse-Midwives “Best Book of the Year” award. An independent scholar, she is an acknowledged expert on evidence-based maternity care.  

Cesarean Birth, Childbirth Education, Epidural Analgesia, Guest Posts, informed Consent, Medical Interventions, New Research, Systematic Review , , , , , , ,

Non-Drug Pain Coping Strategies Improve Outcomes

July 17th, 2014 by avatar

 Today, contributor Henci Goer reviews a recently published study in the journal Birth, that compared the outcomes of births in women who received non pharmacological pain management techniques with women who received the “usual care” treatment.  The researchers found that maternal and infant outcomes were improved.  Take a moment to read Henci’s review to get a glimpse at the results and her analysis.- Sharon Muza, Science & Sensibility Community Manager

© Patti Ramos Photography

© Patti Ramos Photography

In 2012,  the Cochrane Database published an overview of systematic reviews of forms of pain management that summarized the results of the Cochrane database’s suite of systematic reviews of randomized controlled trials (RCTs) of various pain management techniques. Reviewers reached the rather anemic conclusion that epidurals did best at relieving pain—no surprise there—but increased need for medical intervention—no surprise there either—while non-drug modalities (hypnosis, immersion in warm water, relaxation techniques, acupressure/acupuncture, hands on techniques such as massage or reflexology, and TENS) did equally well or better than their comparison groups (“standard care,” a placebo, or a different specific treatment) at relieving pain, at satisfaction with pain relief, or both, and they had no adverse effects (Jones 2012). Insofar as it went, this finding was helpful for advocating for use of non-drug strategies, but it didn’t go very far.

Fast forward two years, and we have a new, much more robust review: Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Its ingenious authors grouped trials of non-drug pain relief modalities according to mechanism of action, which increased the statistical power to determine their effects and avoided inappropriately pooling data from dissimilar studies in meta-analyses (Chaillet 2014). The three mechanisms were Gate Control Theory, which applies nonpainful stimuli to partially block pain transmission; Diffuse Noxious Inhibitory Control, which administers a painful stimulus elsewhere on the body, thereby blocking pain transmission from the uterine contraction and promoting endorphin release in the spinal cord and brain; and Central Nervous System Control, which affects perception and emotions and also releases endorphins within the brain.

Overall, 57 RCTs comparing non-drug strategies with usual care met eligibility criteria: 21 Gate Control (light massage, warm water immersion, positions/ambulation, birth ball, warm packs), 10 Diffuse Noxious Inhibitory Control (sterile water injections, acupressure, acupuncture, high intensity TENS), and 26 Central Nervous System Control (antenatal education, continuous support, attention deviation techniques, aromatherapy). Eleven of the Central Nervous System Control trials specifically added at least one other strategy to continuous support. More about the effect of that in a moment.

Now for the results…

Compared with Gate Control-based strategies, usual care was associated with increased use of epidurals (6 trials, 3369 women, odds ratio: 1.22), higher labor pain scores (3 trials, 278 women, mean difference 1 on a scoring range of 0-10), and more use of oxytocin (10 trials, 2672 women, odds ratio: 1.25). Usual care also increased likelihood of cesarean in studies of walking (3 trials, 1463 women, odds ratio: 1.64).

Compared with Diffuse Noxious Inhibitory Control strategies, usual care was associated with increased use of epidurals (6 trials, 920 women, odds ratio: 1.62), higher labor pain scores (1 trial, 142 women, mean difference 10 on a scoring range of 0-100), and decreased maternal satisfaction as measured in individual trials by feeling safe, relaxed, in control, and perception of experience.

We hit the jackpot with Central Nervous System Control strategies (probably because female labor support, which has numerous studies and strong evidence supporting it, dominate this category [19 labor support, 6 antenatal education, 1 aromatherapy]). As before, usual care is associated with more epidurals (11 trials, 11,957 women, odds ratio: 1.13), more use of oxytocin (19 trials, 14,293 women, odds ratio: 1.20), and decreased maternal satisfaction as measured in individual trials by perception of experience and anxiety. In addition, however, usual care is associated with increased likelihood of cesarean delivery (27 trials, 23,860 women, odds ratio: 1.60), instrumental delivery (21 trials, 15,591 women, odds ratio: 1.21), longer labor duration (13 trials, 4276 women, 30 min), and neonatal resuscitation (3 trials, 7069 women, odds ratio: 1.11).

© Breathtaking Photography http://flic.kr/p/3255VD

© Breathtaking Photography http://flic.kr/p/3255VD

The big winner, though, was continuous support combined with at least one other strategy. Usual care in these 11 trials was even more disadvantageous than in central nervous system trials overall with respect to cesareans (11 trials, 10,338 women): odds ratio 2.17 versus 1.6 for all central nervous system trials, and instrumental delivery (6 trials, 2281 women): odds ratio 1.78 versus 1.21 for all central nervous system trials.

The strength of the data is impressive. Altogether, Chaillet et al. report on 97 outcomes, of which 44 differences favoring non-drug strategies achieve statistical significance, meaning the difference is unlikely to be due to chance, while not one statistically significant difference favors usual care. And there’s still more: benefits of non-drug strategies are probably greater than they appear because on the one hand, “usual care” could include non-drug strategies for coping with labor pain and on the other, many institutions have policies and practices that make it difficult to cope using non-drug strategies alone, strongly encourage epidural use, or both.

The reviewers conclude that their findings showed that:

Nonpharmacologic approaches can contribute to reducing medical interventions, and thus represent an important part of intrapartum care, if not used routinely as the first method for pain relief…however, in some situations, nonpharmacologic approaches may become insufficient…the use of pharmacologic approaches could then be beneficial to reduce pain intensity to prevent suffering and help women cope with labor pain…birth settings and hospital policies . . . should facilitate a supportive birthing environment and should make readily available a broad spectrum of nonpharmacologic and pharmacologic pain relief approaches. (p. 133)

No one could argue with that, but a persuasive argument alone is unlikely to carry the day given the entrenched systemic barriers in many hospitals. States an anesthesiologist: “While there may be problems with high epidural usage, in the presence of our nursing shortages and economic or business considerations, having a woman in bed, attached to an intravenous line and continuous electronic fetal monitor and in receipt of an epidural may be the only realistic way to go” (quoted in Leeman 2003). The Cochrane reviewers concur, writing that using non-drug strategies is “more realistic” (p. 4) outside of the typical hospital environs.

So long as this remains the case, attempts to introduce non-drug options are likely to make little headway. As Lamaze International’s own Judith Lothian trenchantly observes:

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 because they’re unable to work through their pain. . . . I go wild with nurses and childbirth educators who say, . . . “[Women] just want to come in and have their epidural.” I say, “And even if they don’t . . ., they come to your hospital, and they have no choice. . . . They can’t manage their pain because you won’t let them.” (quoted in Block 2007, p. 175)

Success at integrating non-drug strategies will almost certainly depend on addressing underlying factors that maintain the status quo. Can it be done? You tell us. Does your hospital take a multifaceted approach to coping with labor pain? If so, how was it implemented and how is it sustained?


Block, Jennifer. (2007). Pushed: The Painful Truth About Childbirth and Modern Maternity Care. Cambridge, MA: Da Capo Press.

Chaillet, N., Belaid, L., Crochetiere, C., Roy, L., Gagne, G. P., Moutquin, J. M., . . . Bonapace, J. (2014). Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Birth, 41(2), 122-137. doi: 10.1111/birt.12103 http://www.ncbi.nlm.nih.gov/pubmed/24761801

Jones, L., Othman, M., Dowswell, T., Alfirevic, Z., Gates, S., Newburn, M., . . . Neilson, J. P. (2012). Pain management for women in labour: an overview of systematic reviews. Cochrane Database Syst Rev, 3, CD009234. doi: 10.1002/14651858.CD009234.pub2 http://www.ncbi.nlm.nih.gov/pubmed/2241934

Leeman, L., Fontaine, P., King, V., Klein, M. C., & Ratcliffe, S. (2003). Management of labor pain: promoting patient choice. Am Fam Physician, 68(6), 1023, 1026, 1033 passim. http://www.ncbi.nlm.nih.gov/pubmed/14524393?dopt=Citation

About Henci Goer

Henci Goer

Henci Goer

Henci Goer, award-winning medical writer and internationally known speaker, is the author of The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth: The Case for a Physiologic Approach winner of the American College of Nurse-Midwives “Best Book of the Year” award.An independent scholar, she is an acknowledged expert on evidence-based maternity care.  

Childbirth Education, Doula Care, Epidural Analgesia, Guest Posts, Maternity Care, Medical Interventions, Newborns, Research , , , , ,

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) , , , , , , , , , , , ,

Do We Need to Turn Up the Volume on Lamaze’s Healthy Birth Practices? What The Listening to Mothers III Survey Tells Us.

May 14th, 2013 by avatar

Childbirth Connection’s Listening to Mothers Initiative just released the Listening to Mothers III (LTMIII) results late last week.  For the third time in the past 11 years, this organization has gone out and queried women on a variety of topics related to pregnancy, birth, postpartum and breastfeeding.  They have questioned thousands of women to accurately assess how the actual experiences hold up against what we know to be best practice and evidence based maternity care. I have relied on the past two survey results frequently during my professional career in maternal health and am thrilled to have the new survey results now available.

I thought it would be interesting to run some of the LTMIII results through the filter of Lamaze International’s Healthy Birth Practices.  The Healthy Birth Practices were most recently updated by Lamaze in 2009, and consist of six simple, evidence based practices that greatly contribute to keeping birth safe and healthy for mothers and babies. Each easy to remember practice has its own short video that parents can watch that talks about that specific care practice and safe alternatives.  Additionally, each Healthy Birth Practice has an accompanying Practice Paper with all the citations for the peer-reviewed, gold standard research that supports that particular practice.

Some useful links and information upfront

Listening to Mothers I

Listening to Mothers II

New!  Listening to Mothers III

Survey Questionnaire 

Major Study Findings

Interesting facts before we get started

While the LTMIII survey only looked at 2400 women,  please be aware that one percentage point change in results would represent approximately 40,000 mother/baby pairs, based on a US birth rate of around 4 million births a year.

35% of women had not intended to be pregnant at the time of this pregnancy, including 5% who stated that they had never intended to become pregnant at all.

52% of those planning to get pregnant did have a preconception meeting with a health care provider, (which could be viewed as a wonderful time to determine if this health care provider might be a good match for their maternity care needs.)

85% of women based their maternity care provider on insurance requirements or restrictions.

78% of women worked with an obstetrician (this has dropped over the course of the three studies.)

9% of women worked with a family practice doctor

8% of women worked with a midwife who practiced in a hospital, as one of the requirements of the study was that the mother was having a hospital birth.

The average length of time spent actually in a prenatal appointment, with health care provider or their nurse was 32 minutes.  (OB: 31 min, Family Practice/MW 35 min.) I was pleasantly surprised that it was this long, I expected less.

Over the course of the three studies, the cesarean rate of study participants went up, (24% to 31%), the VBAC rate went down and labor augmentation was cut in half from 53% to 26%.  More women used nitrous oxide for pain relief during their labor in the most recent study (6%, up from 2% in the first study)

30% of the women chose not to ask a question that they wanted answered at least once during their prenatal appointments.

Overall, women were unable to make choices in line with the Healthy Birth Practices, and did not know that deviating from these practices was not evidence based and resulted in increased interventions.

Let’s see how things stack up

Healthy Birth Practice 1: Let Labor Begin on Its Own


Research shows that in the absence of medical issues, mothers, babies and labors do best when labor starts spontaneously on its own. The final few weeks of pregnancy are vital for the putting the “finishing touches” on baby and helping to make the transition to life on the outside as smooth as possible.

41% of all women surveyed attempted a medical (involved a care provider) induction and of those induced, 74% were successful, (the woman went into labor) for an overall medically induced labor rate of 31%

Reasons why women were induced

  • 44% were full term
  • 19% wanted to get the pregnancy over
  • 11% wanted to control the timing of birth
  • 16% were induced for a large baby (note: the average weight of these babies induced for suspected macrosomia was 7 lbs 15 ounces.)
  • 18% were induced for being “overdue” (note: the average gestational age of those babies induced for being overdue was 39.9 weeks)
  • 18% were induced for a maternal health problem

Interestingly, 26% of women had their due date changed toward the end of their pregnancy; 66% of those were given an earlier due date and 34% were given a later one.

68% of women had a late third trimester ultrasound to estimate fetal weight

Healthy Birth Practice 2: Walk, Move Around and Change Positions in Labor


Women with the ability to move and change positions are able to use this movement to help cope with the pain of labor.  Access to water in the form of a shower or tub can be a valuable coping technique.  Having access to intermittent fetal monitoring or telemetry movements can facilitate movement and promote labor progress for many women.

Only 43% of women walked around after being admitted to the hospital in labor

40% of women used position changes and movement for non-pharmacological pain relief

Healthy Birth Practice 3: Bring a Loved One, Friend or Doula for Continuous Support

Many women will thrive in labor if surrounded by a caring, supportive birth team.  Adding a skilled birth doula to the team has been shown in many studies to improve the outcome of birth and reduce interventions and cesareans.  While more and more birthing women are aware of a doula, many are still not having one in attendance at their birth.

99% of mothers had at least one support person present, (most often this was a partner, then a family member or friend)

6% women used a doula

75% of mothers were aware of what a doula does and of those 75% who knew, 27% would have liked a doula supporting them at their birth.

Healthy Birth Practice 4: Avoid Interventions That are Not Medically Necessary 


Although research shows that routine and unnecessary interference in the natural process of labor and birth is not likely to be beneficial—and may indeed be harmful—most U.S. births today are intervention-intensive.

98% of the women had at least one ultrasound during pregnancy and 70% had three or more over the course of their pregnancy

68% of women had a late third trimester ultrasound to estimate fetal weight.

83% of women had some type of pain medication

67% had an epidural or spinal, and 92% of those who did reported this to be “very helpful” or “somewhat helpful.”

62% of women surveyed had an IV during labor

51% of women had one or more vaginal exams in labor. (I was surprised at this, I would have suspected higher)

47% had bladder (Foley) catheters

31% of women had a labor augmented with pitocin

50% of birthing women had their labor either induced or augmented with pitocin

20% had their membranes ruptured artificially (AROM)  after labor began

36% of women had their labor started or augmented by AROM

1% of women requested and had a maternal request cesarean for non-medical reasons

40% of women drank fluids during their labor

21% of the women ate during labor

85% of women birthing vaginally did so without forceps or vacuum

87% of women responding had at least one of the five big interventions (attempted labor induction, epidural, pitocin augmentation, assisted delivery with vacuum or forceps or cesarean.

60% of the women had at least two of the above five interventions listed above

Healthy Birth Practice 5: Avoid Giving Birth on Your Back and Follow Your Body’s Urges to Push


Women push most effectively when permitted to push in the positions that feel best for them.  Allowing the baby to “labor down” even after reaching full dilation until moms feel the urge to push can help women to push a baby out quicker and under their own steam.  Pushing in positions that allow the pelvis to open as much as possible and making space by getting the sacrum out of the way can help promote descent during pushing.

68% of women surveyed birthed on their backs

23% birthed in a semi-sitting position

8% gave birth in a position off their back, either side-lying, squat or hands & knees

Healthy Birth Practice 6: Keep Mother and Baby Together; Its Best for Mother, Baby and Breastfeeding

Experts now recommend that right after birth, a healthy newborn should be placed skin-to-skin on the mother’s abdomen or chest and should be dried and covered with warm blankets. Any care that needs to be done immediately after birth can be done with your baby skin-to-skin on your chest.  This early time together promotes breastfeeding, helps stabilize the newborn’s temperature and blood sugar and also offers a unique chance for high levels of natural oxytocin that promote bonding and help with immediate postpartum bleeding.

47% of mothers responding had their baby in their arms within the first hour

40% of mother-baby pairs were not skin to skin when they were first held

33% of all babies were with hospital staff the first hour

60% of mother-baby pairs roomed in together

18% of babies spent time in the NICU

25% of babies spent their days with mom and their nights in the nursery

49% of mothers who stated that they intended to exclusively breastfeed were given formula samples or offers.

29% of newborns were supplemented with water or formula during the hospital stay


After reading through the LTMIII report, I found myself discouraged by the current results.  It was clear that women were making choices and/or being informed by their care providers to choose practices that have long been known to create a cascade of interventions, do not improve outcomes for mothers or babies and are not evidence based.  For the majority of the women who responded to this survey, the Healthy Care Practices are still a pipe dream and not a reality in their hospitals and with their current providers.  I know change comes slowly, and it can take years for protocols to catch up with the evidence but frankly, after reading the summary of how things did or did not change over the course of the three studies I was still shocked.

Have you had a chance to go through the study yet?  What were your thoughts?  Anything surprise you?  Can you share a bright point that you noticed?

Join us later this week as I examine what the LTMIII survey had to say about childbirth education and how women are receiving pregnancy and birth information and from where.





Breastfeeding, Cesarean Birth, Childbirth Education, Doula Care, Epidural Analgesia, Evidence Based Medicine, Healthy Birth Practices, Healthy Care Practices, Lamaze International, Maternal Quality Improvement, Maternity Care, Medical Interventions, Midwifery, New Research, Newborns, News about Pregnancy, Research, Transforming Maternity Care, Uncategorized , , , , , ,