an academic
article
by One of the core issues facing expecting mothers is planning the type of analgesia to use during labor and birth. Options range from going completely without, to being totally unconscious. Right in the middle is epidural analgesia1 – the "most popular means for pain relief during labor." An "epidural" is asked for by name more than any other method of pain relief and is used by over 50% of women giving birth at hospitals."2
The method is not without controversy, however. The media has reported complications with the procedure "turning deadly,"3 and many naturalists claim the risks have been "greatly underplayed."4 In an attempt to assess current research on the topic, I have collected recent academic publications on the effects and implications of epidural analgesia during labor and birth.
Research by Year
Studies and reviews are listed below by their year of release, ranging from 1996 to 2007. Note that while the general findings are only summarized herein and the full studies should be referenced for details.
1996
Overall Risks / Benefits (Publication Review)
A 1996 review entitled Epidural analgesia in labor: an evaluation of risks and benefits found the practice to be be a "safe and effective method of relieving pain in labor." The risks confirmed included:
- longer labor
- more operative intervention
- higher cost
Other risk associations were identified as tenuous and requiring further study, including: - maternal fever in labor
- chronic back pain
- neonatal behavioral changes
- maternal-infant bonding5
1998
Pain Relief Effectiveness
A 1998 study entitled Risk factors of inadequate pain relief during epidural analgesia for labour and delivery assessed the causes of epidural failure among patients delivering vaginally. The study found "inadequate pain relief during labor and during delivery were found in 5.3% and 19.7%" of patients, respectively. The risk factors included:
- inadequate analgesia efficacy of the first dose
- posterior presentation6
- radicular pain during epidural placement
- duration of epidural analgesia greater than six hours
- duration of epidural analgesia less than one hour
Based on these, the study concluded simple changes of practice may lead to improved epidural effectiveness.7
Compared to Parental Opioid Analgesia (Publication Review)
Starting from a claimed context of epidural analgesia being associated with high cesarean delivery rates, a 1998 study sought to compare this risk and others to the use of parenteral opioid analgesia.8 The study involved two independent data extractions from ten trials (2369 patients) and found no difference between the two methods concerning:
- instrumented vaginal delivery9 rates for dystocia10
- cesarean delivery rates
It did, however, identify epidural analgesia as correlating with: - increased rates of instrumental delivery in general
- longer first and second stages of labor11
- lower likelihood of neonate with low 5-minute Apgar scores12
- mothers with lower pain scores in first and second stages of labor
- lower rates of mother dissatisfaction13
2000
Compared to Non-Epidural Analgesia (Publication Review)
A 2000 review widened the scope of the 1998 study to compare epidural analgesia to all other pain relief methods. Eleven studies (3157 women) were included and found epidural analgesia to be associated with:
- greater pain relief
- longer first and second stages of labor
- increased incidence of fetal malposition14
- increased use of oxytocin15
- increased rate of instrumented vaginal deliveries
Concurring with the 1998 review, no statistically significant effect on cesarean section rates was identified.16
2001
Compared to Non-Epidural Analgesia
The author of the 2000 publication review followed up with his own research in a 2001 study entitled A randomised controlled trial of epidural compared with non-epidural analgesia in labour. The study found no significant difference in:
- reported incidence of backache at three months
- reported incidence of backache at twelve months
- maternal satisfaction
It did identify, however, a somewhat higher incident rate of instrumented delivery in the epidural group.17
2002
Compared to Intravenous Analgesia
In the vein of the 1998 review, a 2002 study compared epidural analgesia to an alternative method, this time intravenous analgesia. The study found epidural analgesia, when compared to intravenous analgesia, to:
- provide better pain relief
- have fewer adverse effect
- cost more (including hospital base-line fees and incremental care costs)18
Obstetric Lacerations
A study entitled The effect of epidural analgesia on the occurrence of obstetric lacerations19 and on the neonatal outcome during spontaneous vaginal delivery found epidural analgesia to be a "safe and effective method of pain relief during labour." The following risk associations were found, although it was noted they could be due to the higher rate of primiparous women using epidural analgesia:
- prolonged second stage of labor
- higher rate of episiotomy20
- increased use of oxytocin
No "evidence of a detrimental effect on the integrity of the birth-canal in spontaneous vaginal delivery" was found.21
Long Term Effects vs Non-Epidural Analgesia
The same researcher involved in the 2000 review and 2001 study published a study also in 2002 on the effects of epidural analgesia on long-term backache as compared to non-epidural analgesia. The patients (369 women) were interviewed concerning their back pain an average of 26 months after delivery. The study found no significant differences between women who receive epidural pain relief and women who receive other forms of pain relief as concerning:
- incidence of long term low back pain
- disability
- movement restriction22
Fetal Acid-Base Balance
A 2002 study aimed to determine the effect of epidural analgesia on funic acid-base status23 at birth, as compared to systemic labor analgesia. Studying babies of 2102 mothers in five countries, it found epidural analgesia to be "associated with improved neonatal acid-base status, suggesting that placental exchange is well preserved in association with maternal sympathetic blockade and good analgesia." The conclusion claims the following negative effects of epidural analgesia are outweighed by the benefits to neonatal acid-base status:
- maternal hypotension and fever
- longer second stage of labour
- more instrumental vaginal deliveries24
Patient-Controlled vs Continuous Infusion (Publication Review)
This 2002 review compared the safety and effectiveness of two epidural analgesia application methods: patient-controlled epidural analgesia (PCEA)25 and continuous epidural infusion (CEI).26 The review included nine studies (640 patients) and found both methods of epidural analgesia administration to be safe for mother and newborn. Patients receiving PCEA were found to (as compared to those receiving CEI):
- have fewer anesthetic interventions
- receive less local anesthetic
- receive less monitor block27
2003
Compared with Combined Spinal-Epidural (Publication Review)
Combined spinal-epidural (CSE)28 was introduced in an attempt to reduce the adverse effects of traditional epidural analgesia, listed as:
- prolonged labor
- use of oxytocin augmentation
- increased incidence of instrumental vaginal delivery
This 2003 study evaluates the effectiveness of CSE by looking at maternal satisfaction. The review included nineteen trials (2658 women) and found there to be little difference between CSE and other forms of epidural for pain relief in labor. The conclusions state CSE: - provides faster onset of effective pain relief from the time of injection
- increases the incidence of maternal satisfaction
- causes more itching
There is no difference between CSE and other epidural techniques with respect to the incidence of: - forceps delivery
- maternal mobility
- postdural puncture headache (PDPH)29
- cesarean section rates
- admission of babies to the neonatal unit30
2004
Safety and Effectiveness (Publication Review)
A 2004 review entitled Epidural analgesia for pain relief in labour and childbirth – a review with a systematic approach assessed twenty-four articles with respect to the procedure’s safety and effectiveness. It found "the use of epidural analgesia is considered to be an effective method of pain relief during labour and childbirth from the perspective of women giving birth. … Midwives and doctors can recommend this form of pain relief."31
Discontinuation Late in Labor (Publication Review)
Another 2004 review ascertained the consequences of discontinuing epidural analgesia late in labor in order to avoid possible negative consequences associated with the pain relief technique. The review of six studies found when the epidural analgesia was discontinued there was:
- no statistically significant reduction in instrumental delivery rate, nor in any other delivery outcome rates
- a significant increase of reported inadequate pain relief32
Breast-Feeding Problems
This study investigated breast-feeding problems after epidural analgesia administration during labor. The results of a survey of primiparae33 associated partial breast-feeding or formula feeding during the first 12 weeks with:
- older age of the mother
- use of epidural analgesia
- problem of "not having enough milk" (reported more often by those who had received epidural analgesia)
The following were found not to have any association with the failure to breast-feed fully: - cesarean section
- other methods of labor analgesia
- other breast-feeding problems
The study stops short of claiming a causal relationship between epidural analgesia and breast-feeding problems, however.34
Prophylactic Intravenous Preloading (Publication Review)
This 2004 review of six studies (473 participants) investigated the effects of prophylactic intravenous preloading.35 It found preloading may have some "beneficial fetal and maternal effects in healthy women" prior to traditional high-dose local anaesthetic blocks. There was no identifiable benefit for low-dose epidural or CSE analgesia techniques, however.36
First-Stage Ambulation (Publication Review)
This review of five trials (1161 women) evaluated the effects of first-stage ambulation,37 as there were a number of new techniques for administering epidural analgesia allowing increased mobility for birthing women. The review found there to be no statistically significant difference between women with an epidural who ambulated in the first stage of labour and those who remained recumbent in the following areas:
- mode of delivery (e.g., instrumental, cesarean, etc.)
- use of oxytocin augmentation
- duration of labor
- satisfaction with analgesia
- Apgar scores38
Cesarean Section and Instrumental Vaginal Delivery Rates (Publication Review)
This review compared the effects of low-dose epidural infusions of bupivacaine39 with parenteral opioid analgesia, specifically targeting the resulting rates of cesarean sections and instrumental vaginal deliveries. The results showed epidural analgesia is associated with the following, as compared to parenteral opioid analgesia:
- increased risk of instrumental vaginal delivery
- longer second stage of labor
- better pain relief
It was not associated with an increased risk of cesarean section.40
2005
Compared to Non-Epidural or No Analgesia (Publication Review)
A 2005 study comparing epidural versus non-epidural or no analgesia during labor grouped 21 studies (6664 women) and identified the method as effective. Epidural analgesia administration was found not to be associated with:
- risk of cesarean section
- maternal satisfaction with pain relief
- long-term backache
- Apgar scores
It was, however, found to correlate with an increased risk of instrumented vaginal birth.41
Neurobehavioral and Breast-Feeding Effects
Another 2005 study investigated a possible association between epidural analgesia during labor/delivery, infant neurobehavioral status, and effective breast-feeding. The results found no significant difference between the epidural analgesia and no-analgesia groups in:
- breast-feeding effectiveness at 8-12 hours
- infant neurobehavioral status at 8-12 hours
- the proportion of mothers continuing to breast-feed at 4 weeks42
2006
Self-Hypnosis (Publication Review)
A 2006 review of trials studying complementary and alternative pain management therapies in 2006 identified effects on the need for epidural analgesia specifically. The review included fourteen trials (1537 women) and found women taught self-hypnosis:
- had decreased requirements for pharmacological analgesia including epidural analgesia
- were more satisfied with their pain management in labor43
2007
Stress Urinary Incontinence
A 2007 study investigated a possible correlation between epidural analgesia and stress urinary incontinence (SUI),44 but found none. It did, however, confirm increased risks of:
- prolonged labor
- instrumental delivery
- cesarean delivery
- longer first stage of labor (when analgesia was administered early)45
Summary
The results/conclusions of the above studies and reviews are summarized below as risks, benefits, and other. Risks and benefits are noted with the year of the commenting studies in parentheses, along with a "+" or "-" indicating whether the study confirms or dispels the listed association.
Risks
The publications discussed in this article commented on the following risks of epidural analgesia:
- longer labor (+1996, +1998, +2000, +2004, +2007)
- cesarean delivery (-1998, -2000, -2004, -2005, +2007)
- instrumented vaginal delivery (+1996, +1998,46 +2000, +2001, +2004, +2005, +2007)
- higher cost (+1996, +2002)
- inadequate pain relief (-1998)
- fetal malposition (+2000)
- use of oxytocin (+2000, +2002, -2004)
- long term backache (-2001, -2002, -2005)
- spinal mobility / disability (-2002)
- neonatal behavioral issues (-2005)
- breast-feeding problems (+2004, -2005)
- lower Apgar scores (-2005)
- birth-canal integrity (-2002)
- episiotomy rate (+2002)
- stress urinary incontinence (-2007)
Benefits
The publications discussed in this article commented on the following benefits of epidural analgesia:
- higher Apgar scores (+1998, -2005)
- mother pain relief (+1998, +2000, +2002, +2004)
- mother satisfaction (+1998, -2001, -2005)
- funic acid-base status (+2002)
Other notes
In addition to risks and benefits, the following notes/claims were made in the above studies concerning epidural analgesia:
- PCEA has benefits over CEI. (2002)
- CSE has benefits over traditional epidural analgesia. (2003)
- Discontinuing epidural analgesia late in labor increases pain and does not reduce risk of instrumented delivery. (2004)
- Preloading has benefits over a traditional high-dose local anaesthetic block. (2004)
- Ambulation in the first stage of labor has no positive or negative affect among those having received epidural analgesia. (2004)
- Alternative methods such as self-hypnosis lower the need for epidural analgesia. (2006)
Conclusions
In general, the studies/reviews analyzed indicate epidural analgesia as an effective means of pain relief during childbirth. The undisputed risks seem to be a longer labor, greater cost and higher chance of instrumented vaginal delivery, while the undisputed benefit found is effective pain relief.
Other Labor Pain Relief Studies
The following is an assortment of other interesting studies concerning labor pain relief, listed by general topic and including a brief summary of the findings:
- Water Immersion – "There is evidence that water immersion during the first stage of labour reduces the use of analgesia and reported maternal pain, without adverse outcomes on labour duration, operative delivery or neonatal outcomes."47
- Hynotherapy – "Women who were prepared with the hypnoreflexogenous method had significantly less fear and pain, required significantly less analgesia, had a shorter period of labour and delivery and recovered faster from labour."48
- Continuous Support During Childbirth – "Women who had continuous intrapartum support were less likely to have intrapartum analgesia, operative birth, or to report dissatisfaction with their childbirth experiences. … In general, continuous intrapartum support was associated with greater benefits when the provider was not a member of the hospital staff, when it began early in labour, and in settings in which epidural analgesia was not routinely available."49
- Position in Second Stage of Labor – While concluding "[w]omen should be encouraged to give birth in the position they find most comfortable," this study found the use of any upright or lateral position, compared with supine or lithotomy positions, was associated with:
- reduced duration of second stage of labor
- a small reduction in assisted deliveries
- a reduction in episiotomies
- an increase in second degree perineal tears
- increased estimated blood loss greater than 500 ml
- reduced reporting of severe pain during second stage of labor
- fewer abnormal fetal heart rate patterns50
- Effects of Psychosocial Support During Labor and Childbirth – "Psychosocial support by doulas had a positive effect on breastfeeding and duration of labour. It had a more limited impact on medical interventions, perhaps because of the strict routine in hospital procedures, the cultural background of the women, the short duration of the intervention, and the profile of the doulas. It is important to include psychosocial support as a component of breastfeeding promotion strategies."51
Notes
1 "Epidural Analgesia." University of Wisconsin Hospital and Clinics Authority Board. 2000. Accessed November 2007 from http://www.wisc.edu/trc/projects/pop/Epi-manual.pdf. More information on epidural analgesia in general.
2 "Epidural Anesthesia." American Pregnancy Association. Accessed October 2007 from http://www.americanpregnancy.org/labornbirth/epidural.html.
3 "A routine epidural turns deadly." MSNBC.com. Accessed October 2007 from http://www.msnbc.msn.com/id/9818616/.
4 Mehl-Madrona, Lewis E. MD, PhD. "Medical Risks of Epidural Anesthesia During Childbirth." Healing-Arts.org. Accessed October 2007 from http://www.healing-arts.org/mehl-madrona/mmepidural.htm.
5 Thorp JA, Breedlove G. "Epidural analgesia in labor: an evaluation of risks and benefits." Birth_. 1996 Jun; 23(2):63-83. Accessed October 2007 from http://www.ncbi.nlm.nih.gov/sites/entrez? Db=pubmed&Cmd=ShowDetailView&TermToSearch=8826170&ordinalpos=1 &itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel. Pubmed_RVAbstractPlusRVAbstractPlus.
6 The most common position for a baby’s head during labor is for the back of the head facing the front of the mother. Posterior presentation is when the baby’s head is facing the back of the mother.
7 Le Cog G, Ducot B, Benhamou D. "Risk factors of inadequate pain relief during epidural analgesia for labour and delivery." Can J Anaesth_. 1998 Aug; 45(8):719-23. Accessed October 2007 from http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=9793659&ordinalpos=1 &itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAb stractPlusRVAbstractPlus.
8 Parenteral opioid analgesia is the administration of opioid analgesic (drugs used to alleviate moderate to severe pain that are either opiates or opiate-like) to the mother during labor and/or birth.
9 An instrumented vaginal delivery is when tools, such as forceps, are used to assist in the baby in exiting the mother through the birth canal.
10 Dystocia is an abnormally slow or difficult birth
11 Labor is typically described as having three stages: labor pre-birth, birth of the baby, and birth of the placenta.
12 Apgar scores indicate the result of simple tests given to newborns immediately after birth to quickly assess their health.
13 Halpern SH, Leighton BL, Ohlsson A, Barrett JF, Rice A. "Effect of epidural vs parenteral opioid analgesia on the progress of labor: a meta-analysis." JAMA. 1998 Dec 23-30; 280(24):2105-10. Accessed October 2007 from http://jama.ama-assn.org/cgi/content/full/280/24/2105.
14 Fetal malposition is when the baby’s head is abnormally positioned with respect to the mother’s pelvis. All positions other than the baby facing the mother’s back are considered malpositions.
15 Oxytocin is an important hormone during childbirth. Insufficient amounts of oxytocin can result in various problems, so it is administered intravenously by doctors during labor/birth when deemed necessary.
16 Howell CJ. "Epidural versus non-epidural analgesia for pain relief in labour." Cochrane Database Syst Rev_. 2000: (2):CD000331. http://www.ncbi.nlm.nih.gov/sites/entrez? Db=pubmed&Cmd=ShowDetailView&TermToSearch=10796196&ordinalpos=1 &itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel. Pubmed_RVAbstractPlusRVAbstractPlus.
17 Howell CJ, Kidd C, Roberts W, Upton P, Lucking L, Jones PW, Johanson RB. "A randomised controlled trial of epidural compared with non-epidural analgesia in labour." BJOG. 2001 Jan; 108(1):27-33. Accessed October 2007 from http://www.blackwell-synergy.com/doi/abs/10.1111/j.1471-0528.2001.00012.x.
18 Huang C, Macario A. "Economic considerations related to providing adequate pain relief for women in labour: comparison of epidural and intravenous analgesia." Pharmacoeconomics_. 2002; 20(5):305-18. Accessed October 2007 from http://www.ncbi.nlm.nih.gov/sites/entrez? Db=pubmed&Cmd=ShowDetailView&TermToSearch=11994040&ordinalpos=1 &itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel. Pubmed_RVAbstractPlusRVAbstractPlus.
19 Obstetric lacerations are cuts (due to an episiotomy) or tears in the wall of the vaginal opening occuring during childbirth.
20 An episiotomy is an incision made through the perineum to enlarge the vagina during childbirth.
21 Bodner-Adler B, Bodner K, Kimberger O, Wagenbichler P, Kaider A, Husslein P, Mayerhofer K. "_The effect of epidural analgesia on the occurrence of obstetric lacerations and on the neonatal outcome during spontaneous vaginal delivery." _Arch Gynecol Obstet’’. 2002 Dec; 267(2):81-4. Accessed October 2007 from http://www.springerlink.com/content/bthah66u3jwx0kcl/.
22 Howell CJ, Dean T, Lucking L, Dziedzic K, Jones PW, Johanson RB. "Randomised study of long term outcome after epidural versus non-epidural analgesia during labour." BMJ. 2002 Aug 17; 325(7360):357. Accessed November 2007 from http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=12183305.
23 The acid-base status of newborns’ umbilical cord gases is an indicator of fetal oxygenation just prior to birth and serves, similar to Apgar scores, to help identify at-risk newborns.
24 Reynolds F, Sharma SK, Seed PT. "Analgesia in labour and fetal acid-base balance: a meta-analysis comparing epidural with systemic opioid analgesia." BJOG. 2002 Dec; 109(12):1344-53. Accessed November 2007 from http://www.blackwell-synergy.com/doi/abs/10.1046/j.1471-0528.2002.01461.x.
25 In patient-controlled epidural analgesia, the mother self-administers small doses of local anaesthetic through her epidural.
26 In continuous epidural infusion, the mother is administered a continuous dose of anaesthetic through her epidural as determined by the setting of a computer-controlled pump.
27 van der Vyver M, Halpern S, Joseph G. "Patient-controlled epidural analgesia versus continuous infusion for labour analgesia: a meta-analysis." BR J Anaesth. 2002 Sep; 89(3):459-65. Accessed November 2007 from http://bja.oxfordjournals.org/cgi/content/full/89/3/459’’.
28 A combined spinal-epidural involves using both a spinal and an epidural for pain relief. A spinal, which takes effect faster than an epidural, is when the anaesthetic drug is injected into the spinal column.
29 Postdural puncture headache is a headache occuring in patients who have undergone an accidental dural puncture with epidural insertion. PDPH occurs as early as one day and as late as seven days after dural puncture and lasts 12 hr to seven days.
30 Hughes D, Simmons SW, Brown J, Cyna AM. "Combined spinal-epidural versus epidural analgesia in labour." Cochrane Database Syst Rev. 2003; (4):CD003401. Accessed November 2007 from http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003401/frame.html.
31 Nystedt A, Edvardsson D, Willman A. "Epidural analgesia for pain relief in labour and childbirth Рa review with a systematic approach." J Clin Nurs_. 2004 May; 13(4):455-66. Obstetrics and Gynaecology, Department of Clinical Science, Ume̴ University, Ume̴, Sweden. Accessed October 2007 from "http://www.ncbi.nlm.nih.gov/sites/entrez? Db=pubmed&Cmd=ShowDetailView&TermToSearch=15086632& ordinalpos=1 &itool=EntrezSystem2.PEntrez.Pubmed. Pubmed ResultsPanel.Pubmed_RVAbstractPlus":http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15086632&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus.
32 Torvaldsen S, Roberts CL, Bell JC, Raynes-Greenow CH. "Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia." ’’Cochrane Database Syst Rev." 2004 Oct 18; (4):CD004457. Accessed November 2007 from http://www.ncbi.nlm.nih.gov/sites/entrez? Db=pubmed&Cmd=ShowDetailView&TermToSearch=15495111&ordinalpos=1 &itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel. Pubmed_RVAbstractPlus.
33 A primipara is a woman who is pregnant for the first time.
34 Volmanen P, Valanne J, Alahuhta S. "Breast-feeding problems after epidural analgesia for labour: a retrospective cohort study of pain, obstetrical procedures and breast-feeding practices." Int J Obstet Anesth. 2004 Jan; 13(1):25-9. Accessed November 2007 from http://www.sciencedirect.com/science? ob=ArticleURL&udi=B6WGV-4B6K57P- 7&user=5381732&coverDate=01%2F31% 2F2004&rdoc=1&fmt=&orig=search&sort=d&view=c&acct= C000066906&version=1&urlVersion=0&userid=5381732&md5= 7279c449d9d105ea7af0885e51c52891.
35 Prophylactic intravenous preloading is the practice of administering fluid intravenously to a mother (volume expansion) prior to labor/birth to help reduce maternal hypotension during labor/birth.
36 Hofmeyr G, Cyna A, Middleton P. "Prophylactic intravenous preloading for regional analgesia in labour." Cochrane Database Syst Rev_. 2004 Oct 18; (4):CD000175. Accessed November 2007 from http://www.ncbi.nlm.nih.gov/sites/entrez? Db=pubmed&Cmd=ShowDetailView&TermToSearch=15494990&ordinalpos=8 &itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel. Pubmed_RVDocSumRVDocSum.
37 First-stage ambulation is walking during the first stage of labor.
38 Roberts CL, ALgert CS, Olive E. "Impact of first-stage ambulation on mode of delivery among women with epidural analgesia." Aust N Z J Obstet Gynaecol. 2004 Dec; 44(6):489-94. Accessed November 2007 from http://www.blackwell-synergy.com/doi/abs/10.1111/j.1479-828X.2004.00294.x.
39 Bupivacaine is a local anaesthetic drug.
40 Liu EH, Sia AT. "Rates of caesarean section and instrumental vaginal delivery in nulliparous women after low concentration epidural infusions or opioid analgesia: systematic review." BMJ. 2004 Jun 12; 328(7453):1410. Epub 2004 May 28. Accessed November 2007 from http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=15169744.
41 Anim-Somuah M, Smyth R, Howell C. "Epidural versus non-epidural or no analgesia in labour." Cochrane Database Syst Rev. 2005 Oct 19; (4):CD000331. Accessed November 2007 from http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000331/frame.html.
42 Chang ZM, Heaman MI. "Epidural analgesia during labor and delivery: effects on the initiation and continuation of effective breastfeeding." J Hum Lact. 2005 Aug; 21(3):305-14. Accessed November 2007 from http://jhl.sagepub.com/cgi/content/abstract/21/3/305.
43 Smith CA, Collins CT, Cyna AM, Crowther CA. "Complementary and alternative therapies for pain management in labour." Cochrane Database Syst Rev. 2006 Oct 18; (4):CD003521. Accessed November 2007 from http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003521/frame.html.
44 Stress urinary incontinence is the involuntary loss of urine due to increases in abdominal pressure.
45 Liang CC, Wong SY, Chang YL, Tsay PK, Chang SD, Lo LM. "Does intrapartum epidural analgesia affect nulliparous labor and postpartum urinary incontinence?" Chang Gung Med J_. 2007 Mar-Apr; 30(2):161-7. Accessed October 2007 from http://www.ncbi.nlm.nih.gov/sites/entrez? Db=pubmed&Cmd=ShowDetailView&TermToSearch=17596005&ordinalpos=4 &itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel. Pubmed_RVDocSumRVDocSum.
46 Although the 1998 study found there to be no increased risk of instrumented vaginal delivery for dystocia, an increased risk was identified in general.
47 Cluett ER, Nikodem VC, McCandlish RE, Burns EE. "Immersion in water in pregnancy, labour and birth." Cochrane Database Syst Rev. 2004; (2):CD000111. Accessed November 2007 from http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000111/frame.html.
48 Reinhard J, Husken-Janssen H, Schiermeier S. "Childbirth Preparation through the Hypnoreflexogenous Protocol Developed by Schauble." Z Geburtshilfe Neonatol. 2007 Aug; 211(4):162-4. Accessed November 2007 from http://www.thieme-connect.com/DOI/DOI?10.1055/s-2007-981261.
49 Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. "Continuous support for women during childbirth." Cochrane Database Syst Rev. 2003; (3)CD003766. Accessed November 2007 from http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003766/frame.html.
50 Gupta JK, Hofmeyr GJ. "Position for women during second stage of labour." Cochrane Database Syst Rev. 2004; (1):CD002006. Accessed November 2007 from http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD002006/frame.html.
51 Langer A, Campero L, Garcia C, Rynoso S. "Effects of psychosocial support during labour and childbirth on breastfeeding, medical interventions, and mothers’ wellbeing in a Mexican public hospital: a randomised clinical trial." Br J Obstet Gynaecol_. 1998 Oct; 105(10):1056-63. Accessed Novemeber 2007 from http://www.ncbi.nlm.nih.gov/sites/entrez? Db=pubmed&Cmd=ShowDetailView&TermToSearch=9800927&ordinalpos= 113&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSumRVDocSum.
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That sure cleared it up...not by Anonymous :: NR0
While one can appreciate the effort the author exhibits in attempting to present these findings, the findings don’t really mean anything if they aren’t presented in the context of the scientific studies. I think such "summary" articles serve as a disservice to people since they rarely incorporate the conclusion/discussion sections of the articles but rather seek to just present results. Results need to be reported in the context of the experimental design otherwise they will be misrepresented as straight correlations. For instance, the article cites from a multiple of articles that epidurals increase the likelihood of instrument assisted labor, yet the author doesn’t discuss, as the study must have, the nature of the experimental groups. For instance, many hospitals that administer epidurals will also administer labor inducing drugs in conjunction. This is true of episiotomy as well, since women with pain management are often not consulted and don’t even feel the incision. One must ask what is the intent of the scientific investigation? Were the researchers concerned with actual risks/benefits of said procedure, or were they merely attempting to report on the common practices associated with the procedure (Follow me here…). One can either investigate cause/effect of something, in which experimental design is critical, or one can investigate common associations with something, in which experimental design isn’t relied on as heavily, in order to establish associations for further investigation. Without an explanation of the experimental design and intent of the research one is left to guessing what the intentions of the researchers may or may not be. And without a summary of the discussion/conclusions of the experiments, then one can’t further apply the results and give weight to them.
Again while I would agree that it is useful to compile such a list of pro/cons based on medical research, to dismiss the publications discussions on reasons why the correlations may be skewed is presumptious at best, and intentionally misleading at worst. I understand this isn’t a publication, but I would hope that people would understand that these studies are only as good as the experimental units, and with most medical research that doesn’t involve discrete case studies there will inevitably be weak correlations presented with the intention for further analysis to be done.
I think that it would be a benefit to people if the experimental designs of said studies were at the very least summarized so that people can better judge the merits of said correlation. As it is now, I have no idea if the researchers merely reviewed hospital records or sought to minimize as many external variables as possible.
-brad
real life experience by Anonymous :: NR0
I have found as a labor and delivery nurse that the results of the studies are not necessarily accurate.
In any delivery, with or without an epidural, there are interventions that nurses/medical personnel impliment to prevent/correct malpositions, the need for the use of pitocin, the need for an episiotomy, etc.
I would be very interested to know how the studies were performed and what other interventions were performed by the professionals caring for the patients and if the same interventions were used on all patients.
What I have seen as a labor and delivery nurse is the use of epidurals in most (80-95%) cases actually reduces the length of labor, increases patient satisfaction of pain relief, decreases the need for episiotomy, decreases the incidence of perineal tearing, is less harmful to the fetus, decreases maternal anxiety regarding delivery, decreases maternal fatigue and thus increases maternal satisfaction with the whole birthing process and gives the patient more control to assist with the delivery.
There also appear to be several things the studies do not take into account. One of which is that physicians and hospital policies to reduce liability and increase good outcomes of labor and delivery, require patients to have either intermittent or continuous fetal monitoring which in itself reduces the mobility of the maternal patient as the patient is connected to a monitor by cables. The use of the epidural does not change this. Yes, there are some hospitals that do not require this, however, they are not in the majority.
If we consider the physiology of labor and delivery, it must be noted that a woman in pain from labor is not relaxed during contractions. This in itself lengthens the time of labor for first time moms in most cases as well as in multipara patients. During a contraction, patients tense muscles due to the intense pain; this slows the decent and increases the length of labor. With the use of epidurals, the patient does not experience intense pain during a contraction and therefore does not tense muscles, allowing the labor to progress at a more rapid rate. This is shown to be true by patients being in labor for numerous hours without the epidural and making little or very slow progress and then when they get the epidural placed, are able to relax and progress quickly. It is very common to sit a patient up for epidural placement with a cervix that is dilated to 4-6 centimeters and after epidural placement and the relaxation of the muscles to find the patient has progressed very rapidly to 8 cm or more within a very short period of time. I cannot say this happens in every case, but it happens more often than not. Also, since the patient is able to relax after an epidural and actually rest until delivery, the patient has more reserve energy to assist with pushing. Also due to the decrease in patient fatigue, the patient is more likely to have a better bonding experience after delivery and have the energy to actually work on breastfeeding the newborn.
The medication given to patients intravenously crosses the placenta and affects the fetus. This is evidenced by the fetal heart rate tracing which shows decreased variabilty after IV medication. Intravenous medications do not control pain after one dose, but must be repeated to keep the mother comfortable. In cases where the fetal tracing is not reassuring, whether due to the medication administered or other reasons, the patient does not have the option of repeated doses of pain medication to maintain pain control. The medication given during an epidural does not cross the placenta to the fetus. Fetal distress after an epidural is not due to the medication reaching the fetus, but due to drops in the maternal blood pressure which is easily corrected by giving boluses of IV fluids and in extreme cases, Narcan, a medication that reverses the effects of the medication. This drop of blood pressure is easily prevented by assuring the patient is properly hydrated prior to the placement of the epdiural. In most hospitals, the epidural once started is continuous drip which keeps the patient comfortable until after delivery at which time the drip is discontinued.
Due to the fact that the patient is not out of control due to pain and/or the urge to push, the incidence of episiotomy/perineal tearing is reduced as the pushing process is more controlled with an epidural. This increased control gives the patient/nurse more time to stretch the perineum which decreases the incidence of episiotomy/perineal tearing. A patient that is in intense pain from the delivery process cannot always control the urge to push.
As with everything is life, there are downsides otherwise known in the medical profession as "risks and hazards" in labor and delivery. Some of the risks and hazards of epidurals as listed in the studies may have been the direct result of the individual physician practices. There are many physicians who do not allow patients to progress naturally through labor and delivery without the use of interventions to speed the progress of labor and/or delivery, including the use of pitocin, forceps, vacuum extraction and/or Cesarean sections. This is often a result of the physician preference to "get a good night’s sleep" (i.e. not be called for delivery in the middle of the night), a busy office practice, need to be in meetings, desire to be with their own family for events/family time or numerous other life distractions. This varies of course from physician to physician; just ask any labor and delivery nurse to find out which physicians are more likely to rush to a Cesarean section, use forceps or vacuum extraction, use pitocin, use artificial rupture of membranes to speed labor, etc. In defense of the physicians, most patients to not want to spend 12-48 hours in labor/pain. The physicians are also under pressure from the patients and hospitals to speed up the labor process to "facilitate effective use of labor and delivery personnel". There is a nursing shortage after all. Nurses are not allowed the luxury of sitting at a patient’s bedside (one on one) during labor and delivery. Although in high risk cases, a patient may have a nurse full time, the "normal" laboring patient has to share her nurse with 1-3 other patients, depending on hospital policy and/or the shortage of labor and delivery personnel.
As with any science, it is possible to sway "studies" to reveal the results the scientist is looking for, whether or not it is intentional. Other factors that can alter the outcome of studies is the attitudes and expectations of the patients in the actually study. Do they want an epidural, does someone try to talk them out of the epidural pain relief (yes, this happens often), are they afraid of needles, have they heard "horror" stories from "friends or family" about being paralyzed for life or other side effects of epidurals, have they been educated on the process of epidural placement and what to expect from epidural analgesia. Many factors affect the outcome of studies.
What I have seen during my experience as a labor and delivery nurse is that epidurals usually shorten the length of labor and increase maternal satisfaction with the labor and delivery process.
Basically, whether or not to have an epidural during labor/delivery, should be decided by the patient that has been educated regarding the process of epidural placement and not the outsome of a study. Unfortunately, not all patients are given the education of what to expect from an epidural and the placement procedure. Again, unfortunately, not all anesthesiologists place epidurals in the same manner, use the same medications in the epidural and do not all have the same skills in placing epidurals. Many anesthesiologists aim for the "total pain relief" epidural while others aim for "taking the edge off the pain and allowing for more control during the labor/delivery process".
There have also been labels given to maternal patients if they choose to have an epidural. In some cultures, women are urged to endure the pain which supposedly makes them more of a woman for having natural childbirth. Trust me, delivering the head of an newborn (roughly the size of a large grapefruit) through an opening the size of a plum incurs pain and the patient does not get any extra credit for doing it with intense pain.
Studies have there place. I just feel that each patient needs to take into consideration what can actually affect the outcome of the study. Each patient also needs to take into account what they hope to get out of the labor/delivery experience. I feel that there are a lot of unsubstantiated misconceptions regarding the placement of epidurals due to all these studies that have had such varied results. I have also noted that a lot of these studies are conducted by the male of the species and trust me, they do not have the same perspective as a female on the labor and delivery process.
From a real life perspective, I have not seen epidurals slow labor, increase the incidence of Cesarean section/mechanically assisted delivery or unfavorable effects on the fetus. If anything, I see increased satisfaction with the process, decreased fatigue and better control by laboring patients (which decreases incidence of mechanically assisted deliveries) and a shorter course of labor.
Just thought you might like to have an opinion from someone who does this for a living. Unfortunately for Brandon, that also happens to be his mother-in-law!
Brandon did you only reference abstracts? by bradsmith :: NR5
I signed in this time for you.
You’ve had me going on and on about my critique of your article, and you have protested about having to summarize the cited studies’ experimental designs, and yet now it is unclear if you read the articles yourself!
Something you said in your last comment to me tipped me off. You said that those seeking further context could go on to the next step that being to read the cited article abstracts. Well thought got me thinking, are your references to entire papers or are they to just abstracts. And low and behold, the majority of your "study" references only contain abstracts. Since I work at a university I can access the full text of the articles but others would have to pay for access. So I have to ask, did you only read abstracts on these studies?
I think it is important to convey to others that an abstract gives one a very limited view of an article, usually just the results and limited conclusions. You don’t cite an article if you only read the abstract.
So I am very interested in knowing if you read all of these articles or not.