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evidence based medicine, pregnancy

Getting advice on the safety of pain medication in labor from the NEJM and not The Atlantic

Several tweeps sent me a link to this article, The most scientific birth is often the least technological” in The Atlantic. There are some things that are scientifically okay with the article and some things that are not. To do justice to the how and where to have the safest birth possible really requires a textbook. An up to date textbook. The author mentions the scientific data that she used back in 2000, but I’m here to tell you that anything older than three years in medicine is older than dirt. Meaning, if you want to write an up to date article in 2012 you don’t reference Y2K.

Full disclosure. If you don’t already know, I am an OB. I also believe in evidence based medicine and reproductive choice, which doesn’t just mean abortion. Choice also applies to where you want to have your baby, the pain control you get, the contraception you choose, and so on. I am also an OB who was trained to deliver breeches and twins vaginally as well as being schooled in the art of forceps. I am proud to say that my training program, a massive tertiary care center, had a c-section rate of 15% and when I practiced OB my c-section rate was less than 10%. But I also cared for low risk women, all insured with a decidedly lower than average rate of obesity. High-risk patients were transferred to my high-risk colleagues.

I can’t do justice to all the aspects of The Atlantic’s article in this post, but I can take great opposition to the statement on the apparent lack of safety concerning analgesia (pain control). The quote:

“According to the best studies available, when it came time to birth at the end of my low-risk pregnancy, I should not have…pain medications…”

For most American women, pain medication in labor means an epidural and so I will confine my discussion to epidural anesthesia.

I consulted a 2011 Cochrane Review on Epidural Anesthesia as well as a 2010 review in the New England Journal of Medicine (2010) written by Dr. Joy Hawkins, one of the most respected obstetrical anesthesiologists, not just in the United States but probably in the world. Disclosure again – she is also the doctor who placed the epidural for my c-section, but we are not friends we were merely colleagues at the same institution. She just happened to be on call when I was in need. My epidural was for a c-section as labor was not a choice in my situation.

So, these are the risks of an epidural…

1) Is there an increased risk of a c-section? No, there is a mounting body of evidence to say the relative risk of a c-section with an epidural is 1.07 (no difference from unmedicated). Not even if the epidural is started early (less than 4 cm dilated). Don’t blame epidurals for the obscenely high c-section rates.

2) Does an epidural increase the length of labor? Yes, the 2nd of stage of labor (the time from being fully dilated to having the baby) is extended approximately 15 minutes.

3) Does an epidural increase the risk of needing a vacuum delivery or forceps (an instrumental delivery)? It appears to increase the risk by about 50%. So, if 10 women out of 100 were to need an instrumental delivery, with an epidural 15 women would. This does not meet any definition of unsafe.

4) Does an epidural increase the need for oxytocin ( a drug to stimulate contractions)? It may for 20% of women, although the jury is still out. Again, oxytocin does not result in “less safe” deliveries.

5) Does an epidural affect the baby? About 10-20% of babies will have a drop in heart rate after the epidural is placed. This is typically due to fluid shifts in the mom affecting blood flow to the uterus. There are ways to prevent and treat this. APGAR scores are unaffected and there is no evidence to say these temporary drops in heart rate have any long-term implications.

6) Will an epidural damage the spine or nerves? The risk of persistent neurologic injury after an epidural is 1 per 240,000 women. Persistent injury may be a small patch of numbness, but in very rare cases it can mean weakness in a leg or more serious damage to the nervous system. Back pain is no higher after an epidural compared with a spontaneous, unmedicated labor and delivery.

7) What about headache? Approximately 0.7% of women who get an epidural in labor will get a bad headache the next day (think hangover headache). It can typically be treated.

8) Death. If the epidural block is done too high in the spinal cord the ability to breath can be affected. A skilled anesthesiologist will recognize this immediately and be able to intervene and assist with breathing until the effect wears off. If the medications bupivacaine or ropivacaine are inadvertently injected into the blood stream during the procedure the effects can be fatal without immediate, specific intervention. This can happen anytime these medications are used. The event is so rare in a modern obstetrical unit that it is hard to know how often this happens.

9) Does an epidural affect breast-feeding? Studies are not of the highest quality, however, large doses of the drug fentanyl in an epidural may have an impact and so large doses of this drug should be avoided.

How well does an epidural work? Well, in one study, when compared to women who had a unmedicated delivery with a midwife, women who have an epidural reported they had significantly less pain in labor. That will be of extreme significance to some women and of no significance to others.

Every good doctor should discuss options and risks. Ideally, data just like I have presented should be provided during pregnancy so women can consider their choices when they are in a low stress setting. Some women need pain control and others do not. It’s not my place to judge, just to offer the information.

An epidural is a choice. For some women the risks I have described will seem very high and to others these risks will seem very low. But let’s get one thing straight, the best studies (because those are the one included in Cochrane reviews and in Dr. Hawkins article) do not say that low risk women should not have pain medications. Then again, if The Atlantic had included references I could check them.

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Discussion

13 thoughts on “Getting advice on the safety of pain medication in labor from the NEJM and not The Atlantic

  1. Thank you for presenting this in an honest and non-judgmental way. Even as a crunchier mom, I believe the truth (as usual) lies somewhere in the middle.

    Posted by Kylie | March 20, 2012, 6:00 pm
  2. Do you happen to know what the risk of infection is with an epidural?. I ask because I got a staph infection at my epidural site with my second delivery. I think it was MRSA because I was treated with vancomycin. My OB said she’d never seen a similar case. Do you have any details on infection risk?

    Posted by Judith Graham | March 20, 2012, 6:05 pm
    • I believe and epidural abscess (a dangerous infection close to the spinal cord) is about 1 in 500,000. A skin infection that doesn’t extend to the epidural space is probably a little more common, but less serious.

      Posted by Dr. Jen Gunter | March 24, 2012, 7:41 pm
  3. I only recently found your blog, but I love it! Thank you for your honest and forthright writing on issues so important to women! (Or, that at least SHOULD be important to women!).

    I noticed a typo of significance in your post. I hope pointing it out is helpful, not annoying. But in point #3 you start off by saying, “Does a c-section increase the chances of needing a vacuum delivery or ferceps.” It should say, epidural, as you know. I certainly hope a c-setion never results in the need for vacuum or forceps! If so, that OB is doing something terribly wrong! :)

    Posted by Kristen | March 21, 2012, 11:49 am
  4. Thank you for this very sensible post. I left a parenting/pregnany blog that I was following closely because it started bashing mothers who choose an epidural over natural methods, for no other reason than epidurals are not natural.

    Posted by Anonymous | March 21, 2012, 4:28 pm
  5. As a pharmacist and a mom, I think one should get a PCA pump initiated the moment after they pee on the stick ;)

    Posted by Combat boot PPh | March 22, 2012, 10:52 am
  6. Thanks for this, I’m one of the tweeps who sent you the link, and love that you wrote about it! This is the first I saw this post! I usually check your site on my phone, but the other day I did on the computer and realized I was missing posts (mobile site only shows ‘featured’ posts, at least that I could see). So this time I went to full site and saw all these posts I’ve been missing!

    Posted by Amy (T) | April 8, 2012, 4:51 pm
  7. The lack of up-to-date information on the impact of epidural on c-section rates caused me to forego pain relief in my last labor. Thank you for this blog and the reference – I have hope that I may be able to request pain relief this time around, without increasing my risk for surgery. I plan to discuss options with my doctor, who was incidentally the only doctor within driving distance willing to ‘allow me to try’ a vba2c last time.

    Posted by Laura | April 25, 2012, 8:10 pm
  8. Question about the relationship between epidural and instrumental delivery, and epidural and pitocin: Has anyone proven that the epidural CAUSES the need for instrumental delivery or pitocin? Or is it simply a relationship, a correllation? What if women who are having more difficult, drawn-out labors that are more likely to require instruments and pitocin are also the ones in enough pain to request epidural pain relief? 

    I doubt you could ever effectively prove that epidurals result in the need for instruments and pitocin, mostly because the best way to do it would be to randomize women requesting pain relief into “epidural” and “no epidural” groups, and it would be unethical to deny women pain relief when they request it. 

    I do seem to recall reading a study where women requesting pain relief were randomized into “epidural” and “IV narcotic” groups, and that is how it was determined that epidurals do not slow labor. The IV narcotic group actually had longer labors. I can’t find a citation. 

    I did find a citation for a study that determined that pain relief with epidural v. IV narcotics had no difference in the rate of C-section or instrumental delivery. The study is old-ish, from 2004, but without access to more sophisticated journal searching, I’m not likely to find a newer one. 
    http://www.ncbi.nlm.nih.gov/pubmed/15502060

    Bottom line: I really worry about suggesting that epidurals cause the dreaded interventions. It doesn’t make sense. There have to be confounding factors. So I think we need to be careful about how we discuss this.

    Posted by Andrea | June 13, 2012, 7:49 pm
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Trackbacks/Pingbacks

  1. Pingback: Our Fearless Birthing Story | Drop by Drop We Fill the Pot - March 29, 2012

  2. Pingback: Evidence Lacking In Benefits Of Non-Drug Pain Relief In Labor - April 9, 2012

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