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.