Tuesday, November 2, 2010

Epidurals: When Researchers Disagree

Written by Birth Sense

In my last post, I discussed findings from a recent study,EpiduralAnalgesia and Risk of Cesarean and Operative Vaginal Deliveries in Nulliparous and Muultiparous Women. Nguyen, et al., concluded that epidural analgesia was associated with a significantly increased risk of labor ending in cesarean birth or need for forceps/vacuum assistance. While the Nguyen study had some weaknesses, it is unique in recent epiduralstudies in that it attempted to control for confounding factors by grouping study participants according to their estimated propensity for use of an epidural. Findings of increased risk persisted across all five groups; even women who had previously given birth (multiparous) had an increased risk of c-section.

The results of this study appear to contradict several other studies from recent years, which claimed no significant difference in c-section rates, regardless of how early an epidural was administered. Henci Goer wrote an excellent critique of several of these studies, which you can read here.

The Nguyen study is unique in the efforts of the researchers to minimize confounding factors, but still does not examine physiologic birth in comparison to birth with an epidural. Since we don’t have studies (to my knowledge) that compare physiologic birth — and by that, I mean a birth that occurs without interventions — with epidural analgesia during labor and birth, how are we to interpret the seemingly contradictory findings of many of these studies?

■Some of these studies were conducted by anesthesiologists/anesthetists, who may have a different agenda when it comes to ’safe birth’. The last hospital where I had privileges did not have 24/7 anesthesia inside the hospital. Anesthesia was on call and within 30 minutes of the hospital. The anesthesiologists became frustrated with having to come in to the hospital at 3 a.m. to administer an epidural. They began making “rounds” of all laboring women at 9 p.m., telling them it was their “last chance” for an epidural until 6 a.m. the following morning. Labor would get much worse, and if they didn’t take the epidural now — even if they felt they didn’t need it now — they couldn’t have it until the next morning. Many women, fearful of the unknown, got the epidural even though they didn’t feel they needed it at the time and weren’t sure they would want one at all. The OB providers tried to present evidence that early administration of an epidural increased c-section rates, but the anesthesia department countered with evidence showing that timing of the epidural was insignificant.

■There can be huge differences in how epidurals are administered. What type of medication is used, whether the epidural is a continuous lumbar epidural, intrathecal, or combined spinal/epidural, can all affect outcomes.

■Reasons that epidurals are requested should be considered. For example, does the woman who is having a normal, textbook labor but just doesn’t want to deal with the pain so requests an epidural have a different outcome than the woman who is having a long, slowly progressing labor with a baby who is sunny-side up (posterior)?

■It is important to remember that women are individuals who may respond to an epidural in different ways. I have seen a woman’s labor totally stop following an epidural. This has happened frequently enough that I warn my clients who request epidural that this is a possible risk of epidural analgesia. On the contrary, I have also seen women who have had unusually painful labors because of back labor request an epidural. Once their pain is completely relieved and their muscles completely relaxed, they have dilated rapidly to complete and were able to push their baby out.

So what’s the take-home lesson here?

■Each woman needs to be informed of the continuing controversy over effects of epidural analgesia. She should have a clear understanding of possible risks. This informed consent needs to happen long before labor begins, and ideally would be a dialogue between patient and provider over several visits, allowing the woman time to do research of her own and formulate her own ideas and questions.

■All nurses working in labor and delivery should be highly educated in methods of helping women cope with labor pain using alternative comfort measures. I believe many women in labor resort to epidurals because they don’t have strong support for pain relief alternatives from their labor nurse.

■Women need to understand that an epidural is not an all-0r-nothing intervention. Epidurals can be given at a lower dose, and while not relieving all pain, can give enough relief to allow the woman to rest and relax with contractions. This can be the perfect intervention for someone who is exhausted from a very long labor, actually helping them to be able to deliver vaginally.

■Patience of the provider is critical. There is no need to place a time limit on the second stage of labor with an epidural provided progress is being made (even if it is slow progress) and mother and baby are coping well with labor. I have had healthy babies and mothers after a second stage lasting four to seven hours, without adverse effects. Many hospitals set an aribtrary time limit on how long second stage can last with an epidural, but the truth is, we don’t know the normal length for second stage of labor with an epidural. Passive descent, or allowing the baby to move down naturally without pushing efforts by the mother, is becoming more popular in hospitals, but we’re still putting a time limit on how long it can last! As far as I know, no one has studied how long it takes, on average, for the body to expel a baby entirely through passive descent. This is what we need to know in order to be able to set a time limit for normal second stage of labor with an epidural. I can just about guarantee, however, that it would be longer than two hours.

■If a woman and her provider decide that an epidural might be helpful in her situation, efforts should be made to minimize risks. Duration of epiduralshould be kept to the minimum necessary, as the longer the epiduralis in use, the higher the risk of fever and its consequent antibiotics and blood tests. Positioning should still take advantage of gravity–a woman with an epiduralcan be helped into numerous upright positions, which may help the baby descend. The epiduralcan be turned down or allowed to wear off, with the mother’s consent, during pushing. This can facilitate the mother’s ability and naturalurge to push. Lastly, if an epidural slows labor, there are alternatives to pitocin. Patience and time will often be enough for labor to gradually return to a normal pattern, and labor to proceed without need for augmentation.

More research is recommended by Nguyen and others who have studied epidurals. In the meantime, women can make the best decisions for themselves and their babies in spite of conflicting research, by using a common sense tip: Let birth proceed without interventions as long as labor is progressing normally. If complications occur, consider an epidural only after alternative measures have been tried, and if the benefits are likely to outweigh risks.


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