Epidurals and progression of labour

Today I’m going to investigate the claim made by NCB advocates that epidurals slow down labour.  I use the term “today” loosely,  I have a young infant and he hasn’t quite figured out how to be self-sufficient yet.

“executive summary”

• epidurals prolong the first stage of labour compared to opioids for analgesia – but only by 30 minutes on average
• placement of an epidural may increase or decrease contractions depending on individual factors (maternal position after placement, use of fluid bolus, amount of circulating maternal adrenaline)
• epidurals prolong the second stage of labour compared to opioids for analgesia – but only by 15 minutes on average
• epidurals increase the risk of instrumental vaginal delivery (OR 1.42) but the effect is dose-dependent and is not present if 0.0625% bupivacaine is used (note, most modern units use 0.06% or 0.08% as their standard labour epidural solutions).
• epidurals have no effect on the overall cesarean delivery rate (OR 1.04)
• you can have a neuraxial technique (epidural or combined spinal-epidural) for pain relief/ analgesia at any time during your labour

It turns out that length of labour has been a secondary outcome in quite a few randomized controlled studies on epidural analgesia in labour.  It may seem like a simple problem but the more you think about it, the more difficulties present themselves.  Firstly, how do you define the start of labour when so many different labour patterns are variations of normal?  Secondly, it might seem easy to define the end of the first stage as the time when the cervix has reached 10 cm dilation…but some of the studies didn’t mandate regular cervical exams and those that did chose intervals of roughly 2 hours.  A cervical exam for complete dilatation is generally done when a woman feels “pushy” or complains of rectal pressure.  With a good epidural on board, it is possible that a mom might be fully dilated for a period of time before her sensations prompt caregivers to perform a cervical exam.  RCTs looking at this problem have generally used systemic opioids as the control group on the grounds that it is unethical to deny women pain relief in labour.  We have very little data on how opioids affect the progress of labour so how can you generalize the results to births where the women use no analgesics at all?  Most of these trials have high “cross-over,” to quote the authors of one study in which 245 women were randomized to epidurals or opioids (16):

“Of 245 selected patients, 43 had to be removed from the trial afer labor ensued…Most of the patients removed from the non-epidural group were apparently experiencing severe pain;  they were usually primigravidae whose baby presenting in the occipito-posterior position…The majority of patients removed from the epidural group were apparently normal and usually multigravidas;  their labours were so rapid it was not possible to arrange for an epidural block.”

In addition, you can’t blind caregivers to the type of analgesia used so you can’t remove the possibility that caregiver biases towards women receiving opioids or with epidurals will alter how labour is managed.  The women who agree to participate in the trial themselves may not be representative of women in general.  How many women do you know would be happy to be randomized to an epidural or no epidural?  Most women don’t want that choice taken from them.

Then there is the problem of causation versus association.  This seems to confuse a lot of people but it’s really a simple exercise in Aristotelian logic: all mountains are big…elephants are big…ergo elephants are mountains.  Women with epidurals use more pitocin….pitocin use is associated with a higher rate of C/S…ergo epidurals cause stalled labour and eventually C/S.  Both logical trains in this paragraph have gone severely off the tracks.  No one over the age of 4 would repeat the first…and I think even most 4 year olds would find that statement quite hilarious…but the second “logical” train is all over the internet (the “cascade of medical interventions that ends in an unnecesarean”) and espoused repeatedly by all kinds of people involved with pregnant women…midwives, childbirth educators, doulas…and in case you think I’m being discriminatory, let me just say that I’ve also run into several doctors and LDR nurses that believe this too.

The problem is that women with babies that are OP (sunny side up) or asynclitic (head tilted to the side) or otherwise not in the optimum presentation for labour and delivery tend to experience more pain with contractions…the infamous “back labour” in the case of OP presentation.  These women are more likely to request epidural analgesia.  During labour uterine contractions push the presenting part of the fetus against the cervix causing it to thin and dilate…if the fetal head is not well applied to the cervix that process is going to be slower or may stall.  As the cervix gets stretched, it releases prostaglandins that have actions in intensifying labour (a positive feedback loop, this is also how stripping those membranes can help you go into labour sooner).  If cervical dilation is slow or doesn’t occur, this positive feedback loop is interrupted.  Pitocin/ oxytocin is then used to try to get things back on track but it’s not always successful and it’s easy to see, once you have a deeper understanding of physiology of the labour and delivery process, how there can be an association between epidurals, pitocin and C/S without any causation.

Observational trials (non-randomized) that have found an association between epidurals and prolonged labour and operative delivery, have also found that women who experience more pain in early labour are more likely to have prolonged labours, problems with the fetal heart rate and to require instrumental delivery (23).  More pain will result in more requests for epidural analgesia.  Lets not get confused here…it’s not the epidural per se that is resulting in longer labours, FHR problems and operative or instrumental delivery.

A meta-analysis of nine studies looking at the effect of epidurals on the length of the first stage of labour (dilating to 10 cm) found no difference (8). These studies included women having their first baby (primips) as well as those who were on baby number 2 or more (multips).  The definitions used for the start and end of the first stage of labour differed across studies also.   A single study from Parkland hospital on primips found that women randomly assigned to epidurals had a longer first stage – but only by an average of 30 minutes (20).  There are two randomized studies that had the opposite result however, both Wong et al (22) and Ohel et al (18) found that the duration of the first stage was shorter in women who received an epidural before 4 cm dilation compared to women who didn’t.  Hmm…is that not the opposite of what you hear on message boards all the time?…ie…”if you have to get an epidural, try to wait until after 4 cm or your labour will slow or possibly stop and you’ll end up with an unnecesarean.”  More about that at the end of this post.

Some researchers have found that contractions decrease after an epidural is placed (21) but that most of the effect seems to be due to maternal malpositioning resulting in aortocaval compression by the uterus (ie inadequate left lateral tilt with a wedge under the hip).  There is also an association with a fluid bolus and decreased contraction activity (2, 25).  It used to be standard to give a fluid bolus when placing an epidural but there is no evidence that this practice is beneficial and it may be harmful.  Anesthesiologists stopped doing this routinely and I was never taught to do it.  In one neat little study (15) uterine activity was measured with intrauterine catheters before and after epidurals were placed in 11 primips…there was no change in activity.

An epidural may speed up uterine activity in women who have high levels of circulating adrenaline and noradrenaline due to pain and anxiety (11, 13).  Epinephrine relaxes the uterus.  Take it away and contractions can speed up – we half-jokingly refer to this as an epidural “induction”.  In fact, if you take it away quickly enough, the uterus can become hypertonic and squeeze so hard that a transient fetal bradycardia may occur.  That’s a known effect which is easily treated at the bedside and does not result in an emergency unnecesarean.

What about the second stage?  It’s pretty intuitive to think that labour epidural analgesia, which can be accompanied by some muscular weakness, will result in less effective pushing as well as the loss of feedback during pushing (eg feeling the baby come down with good pushes and not feeling movement with ineffective pushes).  Indeed, meta-analyses show that the second stage is prolonged in women with epidurals by an average of 15 minutes (8, 20).  Some women fear that they are “on the clock” during the second stage…ie if they don’t manage to push the baby out within a certain time limit they will be subject to an unnecesarean or instrumental delivery.  You should know that if the fetus is okay (electronic FHR monitoring does not show non-reassuring status) and progress is being made (even if slow), the American College of OB/Gyns (ACOG)’s position is that a prolonged second stage alone is not an indication for intervention.  Note, this does not mean pushing for four hours at home with a CPM, a situation that is dicey due to lack of monitoring and access to timely intervention.

What about instrumental delivery?  The odds ratio of assisted vaginal birth, from the Cochrane review, is 1.42 for women with an epidural.  The anesthesiology community here thinks there is a dose-related effect.  A denser epidural leads to more pelvic floor relaxation which in turn could interfere with fetal rotation during descent.  We have lots of studies where instrumental delivery was increased by epidural use and some where it wasn’t.  Many different epidural drug concentrations and combinations were used in these studies and there is some evidence that a dose-response effect does occur (7, 10, 14, 17).  For example, the use of instrumental delivery was double in women getting 0.125% bupivacaine in their epidural compared to a saline placebo group(3) but there was no difference compared to placebo for women getting 0.0625% bupivacaine with fentanyl (4).  Right now we’re really struggling with the best combination of epidural meds that will provide good analgesia without increasing the need for instrumental delivery and the solution for any individual woman is likely going to vary.  Anesthesiologists really do care about this – we know from research done by our colleagues that instrumental delivery has risk for mom (more third and forth degree tears, more episiotomy, more risk of fistulae) and more risk for babies if mid-station forceps are required.

If avoiding an instrumented delivery is important to you but you want an epidural, mention this to your anesthesiologist to encourage them to use a lower concentration epidural solution.  We’ll work with you to maximize your chances of achieving the outcome you want.

In terms of Cesarean delivery rates, in the two meta-analyses of randomized controlled trials mentioned earlier, women with epidurals have the same C/S rate as those without (8, 20).  We also have good information from impact studies – before and after studies of C/S rates around the time of epidural introduction to hospitals.  There is a great example for the Tripler Army Hospital in Hawaii.  Before 1993 the epidural rate in this hospital was about 1%.  After 1993, the hospital created a policy that mandated on-demand access to epidurals for women in labour.  In one year, the epidural rate increased to 80%…but the Cesarean delivery rate for primips remained at 19% (24).  Another similar study looked at the National Maternity Hospital in Dublin (9) from 1987 when the epidural rate was 10% compared to 1994 when the epidural rate was 57%.  In both years, the Cesarean rate was 4%.   A meta-analysis of these impact studies, involving over 37 000 women, showed no increase in C/S rates when epidurals were made available.

Retrospective observational studies suggested an increase in C/S rate when epidurals were used prior to 4 cm dilation (1).  However, these studies suffered from selection bias - remember, women who experience more pain early in labour have a higher risk of prolonged labour, instrumental delivery and C/S regardless of whether or not they get an epidural.  Randomized controlled trials to look at this issue have found no association between epidurals in early labour and an increased risk of C/S (5, 6, 12, 22, 18).  This lead the ACOG to release the following statement (1):

“Neuraxial analgesia techniques [epidurals and combined-spinal epidurals] are the most effective and least depressant treatments for labour pain.  The American College of Obstetricians and Gynecologists previously recommended that practitioners delay initiating epidural analgesia in nulliparous women until the cervical dilation reached 4-5 cm.  However, more recent studies have shown that epidural analgesia does not increase the risks of cesarean delivery.  The choice of analgesic technique, agent and dosage is based on many factors, including patient preference, medical status, and contraindications.  The fear of unnecessary cesarean delivery should not influence the method of pain relief that women can choose during labour.”

Couldn’t have said it better myself!  There is no evidence that you need to wait to achieve a certain level of cervical dilation before getting an epidural.  Provided that you can comply with the need to be positioned for placement and to hold still, there is no cut-off for getting an epidural or combined spinal-epidural (CSE) either.  No word of a lie, I’ve put a CSE in someone who was fully dilated at her request.  Why deny someone pain relief when you know she might be pushing for an hour or two?  Now this is within reason, of course.  If the baby is coming fast (ie is pretty much crowning) that’s probably too late!  If you get the run around because you are 9 cm but you can hold still and get into a curled forward position for placement, there is no reason that some crusty old-school anesthesiologist shouldn’t put in your epidural – you just (regrettably) might have to get a little obnoxious about it.

Personally, I don’t care if you get an epidural or not.  Simply not liking the idea is a good enough reason to avoid one if you can…but it really gets my panties in a twist when women decide they don’t want an epidural based on these pervasive lies that they greatly prolong labour or lead to unnecesarians. We are failing women if they are making decisions based on old or inaccurate information.  In fact, if your provider perpetuates these untruths, I would seriously question them on other aspects of their care.  They are either ignorant (these studies have been available since 2000 or earlier – that’s 12 years ago!) or lying to you and I, for the life of me, can’t decide which of those two scenarios is worse.

References:

1. American College of Obstetricians and Gynecologists Committee on Obstetric Practice.  Analgesia and cesarean delivery rates.  ACOG Committee Opinion No 339.  Washinton, DC, ACOG, June 2006.  (Obstet Gynecol 2006; 107:1487)
2. Cheek TG et al.  Normal saline iv fluid load decreases uterine activity in active labour.  Br J Anaesth 1996; 77:632-5
3. Chestnut et al.  The influence of continuous epidural bupivacaine analgesia on the second stage of labor and method of delivery in nulliparous women.  Anesthesiology 1987; 66:774-80.
4. Chestnut et al.  Continuous epidural infusion of 0.0625% bupivacaine-0.0002% fentanyl during the second stage of labor.  Anesthesiology 1990; 72:613-8
5. Chestnut et al.  Does early administration of epidural analgesia affect obstetric outcome in nulliparous women who are in spontaneous labour?  Anesthesiology 1994; 80:1201-8
6. Chestnut et al.  Does early administration of epidural analgesia affect obstetric outcome in nulliparous women who are receiving intravenous oxytocin?  Anesthesiology 1994; 90:1193-1200
7. Comparative Obstetric Mobile Epidural Trial (COMET) Study Group UK.  Effect of low-dose mobile versus traditional epidural techniques on mode of delivery:  A randomised controlled trial.  Lancet 2001; 358: 19-23
8. Halpern et al.  Epidural analgesia and the progress of labour.  In Halpern SH, Douglas MJ, editors.  Evidence-based Obstetric Anesthesia.  Oxford, Blackwell, 2005:10-22.
9. Impey et al.  Epidural analgesia need not increase operative delivery rates.  Am J Obstet Gynecol 2000; 182:358-63
10. James et al.  Comparison of epidural bolus administration 0f 0.25% bupivacaine and 0.1% bupivacaine with 0.0002% fentanyl for analgesia during labour.  Br J Anaesth 1998; 81:501-10
11. Lederman et al.  The relationship of maternal anxiety, plasma catecholamines and plasma cortisol to progress in labor.  Am J Obstet Gynecol 1978; 132: 495-500
12. Luxman et al.  The effect of early epidural block administration on the progression and outcome of labor.  Int J Obstet Anesth 1998; 7:161-4
13. Moir et al.  Management of incoordinate uterine action under continuous epidural analgesia.  Br Med J 1967; 3:396-400
14. Nageotte et al.  Epidural analgesia compared with combined spinal-epidural analgesia during labor in nulliparous women.  N Engl J Med 1997; 337: 1715-9
15. Nielsen et al.  Effect of epidural analgesia on fundal dominance during spontaneous active-phase nulliparous labour.  Anesthesiology 1996; 84:540-4
16. Nobel et al.  Continuous lumbar epidural analgesia using bupivacaine: A study of the fetus and newborn child.  J Obstet Gynaecol Br Commonw 1971; 78:559-63
17. Olofsson et al.  Obstetric outcome following epidural analgesia with bupivacaine-adrenaline 0.25% or bupivacaine 0.125% with sufentanil – a prospective randomized controlled study in 1000 parturients.  Acta Anaesthesiol Scan 1998; 42: 284-92
18. Ohel et al.  Early versus late initiation of epidural analgesia in labour: does it increase the risk of cesarean section?  A randomized trial.  Am J Obstet Gynecol 2006; 194:600-5.
19. Seyb et al.  Risk of cesarean delivery with elective induction of labor at term in nulliparous women.  Obstet Gynecol 1999; 94:600-7
20. Sharma et al.  Labour analgesia and cesarean delivery: an individual patient meta-analysis of nulliparous women.  Anesthesiology 2004; 100:142-8
21. Schellenberg JC.  Uterine activity during lumbar epidural analgesia with bupivaicaine.  Am J Obstet Gynecol 1977; 127: 26-31
22. Wong et al.  The risk of cesarean delivery with neuraxial analgesia given early versus late in labor.  N Engl J Med 2005; 352: 655-65
23. Wuitchik M et al.  The clinical significance of pain and cognitive activity in latent labour.  Obstet Gynecol 1989; 73:35-42.
24. Yancy et al.  Observations on labor epidural analgesia and operative delivery rates.  Am J Obstet Gynecol 1999; 180:353-9
25. Zamora et al.  Haemodynamic consequences and uterine contractions following 0.5 or 1.0 litre crystalloid infusion before obstetric epidural analgesia.  Can J Anesth 1996; 43:347-52

Tags: anesthesiology, birth, epidurals, forceps, labour, vacuum

Risky Shift

Have you ever wondered why seemingly normal, otherwise rational, people end up doing some really stupid s**t?

Risky shift is the phenomenon where a group makes a decision that carries inherently higher risk than a decision that each of the individuals would have made on their own.

For example, your teen assures you that they would never get into a car with someone who has been drinking.  But they, and a bunch of their friends, get into a car with someone who has been drinking.  Once one member of the group makes a move in that direction, the other members of the group tend to reevaluate how they read the situation.  Everyone assumes that someone else knows something they don’t and no one wants to stand out as the naysayer.  This is especially true in a culture, such as ours, that glorifies and rewards risk.

Once a group of people start a discussion on a topic, their positions and opinions become polarized and more extreme.  Those in the middle, the moderates, are either pushed to one extreme or the other or become silenced.  I remember this phenomenon from classroom debates in junior high school.  We would start out as reasonable individuals, able to see both sides of the debate, but as time when on, passions flared, opinions became more extreme and languange became stronger.  The result was seldom pretty and I don’t recall the teachers doing a great job of pulling us all back into the middle.

Hmmm…does this remind you of a certain ongoing political party leadership race?  How many republicans find their stance becoming more extreme over the course of a primary?

The scary thing about social media and the internet, is that a group no longer has to be physically convened to experience risky shift.  You can see great examples of risky shift on facebook and online forums.  The most impassioned voices also carry the most extreme opinions and they drown out everyone else to eventually produce a community of parrots.  The passion is so extreme that dissention is eventually disallowed.

Take the parenting forum at mothering.com for example.  If you suggest allowing some crying around bedtimes and naptimes your post will be deleted.  If you suggest 24/7 babywearing and co-sleeping everyone will agree with you.  If you suggest something else, everyone will suggest babywearing and co-sleeping.

If you travel over to the birth forum and are unsure how you want your birth to go (as if any of us have any control!), you will leave completely impassioned about natural childbirth.  If you are active on the board long enough, you will eventually find yourself thinking it’s reasonable to give birth at home to breech triplets without any sort of birth attendant.  Afterall, how could so many voices be wrong?

If you are wondering about vaccinating your new bundle of joy (unfortunately the other two weren’t “meant to live” and were “born sleeping”) and simply ask for information from your on-line community you will soon think it is completely reasonable to forgo all vaccination on the grounds that they are toxic injections that cause all kinds of learning disabilities and illnesses.

If you talk to your real-life friends about these topics, there will probably be more moderate opinions expressed during the discussion.  Afterall, your friends aren’t hanging out on message boards for the sole purpose of soap-boxing.  As an added bonus, your friends will probably love you even if you choose co-sleeping and they choose extinction as a sleep strategy.  They will probably love you if your baby’s first solid food is rice cereal while their baby cut his gums on avocado.

I guarantee that you can’t say the same for most of your on-line forum “friends.”  Extremists only love other extremists and care more about behavioural decisions than the person making them.  Remember that old parenting adage of love the child but hate the behaviour?  On forums, no one loves you – your behaviour is the only thing that is important.

Some friends, eh?

Tags: forums, MDC, risk, social media

Turns out I’m not immune…

…to the mumps that is.

I’m applying for hospital privileges right now and part of that is providing evidence of immunity to various diseases…measles, mumps, rubella, Hepatitis B, chicken pox etc etc.  Because my vaccination records are currently several time zones away and there is no “official” record of my infection with chicken pox (a photograph of my five-year old self standing naked on the toilet seat while my mom dabs me with calamine lotion is apparently not good enough), my general practitioner and I decided to send my blood for antibody testing.

And that’s how I found out that my vaccinations for mumps either didn’t take or have “run out.”

I’m a danger to self and others.

I’m off to get an MMR shot.

 

Tags: booster shots, medicine, mumps, vaccination

Facebook has an opinion about me and it ain’t pretty…

Last week Facebook announced their IPO.  I learned that Bono is going to make close to 1 billion.  I learned that people hate the new timeline and the security and privacy commission has been asked to investigate it.  I learned that Facebook is sitting on a ton of cash.  But most importantly, I learned that 85% of its revenues come from advertising.

I’ve never noticed the advertising - it’s like I have a hole in my peripheral vision where the ads appear.  But with this impending IPO I got curious…just who does Facebook think I am?  The ads on Facebook are targeted to demographics: age, gender, location and probably to keywords from comments you’ve made, how you’ve captioned your pictures etc.  I thought that maybe the ads would reveal something about myself…a fun and interesting experiment and so much cheaper than psychotherapy.

But not flattering!

Today Facebook thinks that I should buy a ravine lot in Ajax Ontario.  They also want me to learn Angelina Jolie’s weight loss secrets, buy a “dress to impress,” attend a free webinar on KY brand personal lubricant, and then apply for debt-relief counselling.  They also want me to buy a gel cooling pad to sit on.

Yep.  That’s right.  They think I am a dowdy fat suburbanite with hemorrhoids, a mountain of consume debt and a poor sex life.

Zuckerberg you can kiss my fat dowdy suburban ass!  Mind those hems tho, they might not be too attractive.

Who does Facebook think you are?

Tags: advertising, facebook, marketing, social media

Epidurals and Breastfeeding II

Sorry…this post is going to be a TL,DR (too long, didn’t read) for many people so here is the summary:

There are only two studies that are prospective, randomized trials of epidural medications and their effects on breastfeeding.  The first, by Beilin and friends (et. al.) found no association between epidural medications and breastfeeding difficulties (as assessed by both mom and a lactation consultant) at 24 hours after birth.  They found that women who received more than 150 micrograms of epidural fentanyl total were more likely to have stopped breastfeeding at 6 weeks but the drop out rate from the study was high (11%) and the significance of this finding really needs to be tested in another study.  Stopping breastfeeding at 6 weeks also correlated with maternal reports of breastfeeding problems at 24 hours which suggests that those moms that report difficulties could benefit from more lactation support in the postpartum period.

The second study, an RCT by Wilson et al, provides good evidence that epidurals do NOT have an effect on breastfeeding.

Other studies in this area are either cohort or retrospective and do not provide any compelling evidence that breastfeeding is hindered by epidurals.

Blaming epidurals for lack of breastfeeding success is barking up the wrong tree.  With supportive policies in place in the hospital women who want an epidural to decrease their labour pain will be able to breastfeed with the same success as women who chose “natural” childbirth.

Most of the studies I am about to discuss are available, free of charge on the internet.  The rest I got from my University library…for those of you who are interested but who don’t have access, I am happy to email PDFs.

Prior to Beilin et al, studies looking at the effect of labour epidurals were either retrospective, or non-randomized prospective studies.  Theirs was the first prospective randomized trial looking at this important question.

This study comes from the Mount Sinai School of medicine in New York and was published in a well-regarded peer-reviewed journal in 2005.

The authors took a group of pregnant women who had already had at least one baby who they had breastfed for 6 weeks or more and who planned to breastfeed their next baby also.  When they requested an epidural during labour they were assigned into one of three groups:

-       Local anesthetic only, no epidural narcotic

-       Local anesthetic plus up to 150 micrograms of epidural fentanyl total for the duration of the epidural infusion

-       Local anesthetic plus no cap on the micrograms of epidural fentanyl

Women who had IV or IM narcotic during their labour were excluded as were those that had a C/S.  If a woman couldn’t be made comfortable, additional medications (including more fentanyl) were given by the anesthesiologist.  The groups were analyzed two ways: an intention to treat analysis was used keeping all women in their assigned groups, and then a second analysis was done by grouping the women into three groups based on the actual amount of fentanyl they had received.  The trial was double blinded – the woman and those assessing breastfeeding did not know which medications had been used in the epidural.

The outcomes studied were perceived problems breastfeeding by the women themselves, problems observed by lactation consultants and number still breastfeeding at 6 weeks.

When breastfeeding was assessed at 24 hours by moms and lactation consultants, no differences were found between the groups with the exception of “infant fussy, refuses to nurse” reported by moms (p = 0.04).  But with 21 statistical tests, it would be more shocking if none of them proved to be statistically significant.  With a p value of 0.05 set as significant, one out of every 20 comparisons will be significant by chance alone.

21 women couldn’t be reached at 6 weeks or chose not to participate.  At 6 weeks, it was less likely (statistically significant) that women in the high dose fentanyl group were still breastfeeding.  All women who stopped breastfeeding cited difficulties breastfeeding as the reason.  Interestingly, stopping breastfeeding before 6 weeks correlated with women’s perceived difficulties breastfeeding at 24 hours but not the evaluation by the lactation consultant.

I think this study is interesting but not definitive.  The finding that higher dose epidural fentanyl was associated with cessation of breastfeeding at 6 weeks is interesting but doesn’t prove causation.  It wasn’t reported in the paper which groups those 21 women who didn’t respond/ chose not to participate in the 6 week survey belonged to.  If they all came from one group that would probably throw the results off.  In general, when there is a high drop out from a study, the results become less reliable.  What if those 21 women didn’t answer the phone because they were busy breastfeeding?  What if those 21 women had to go back to work and so weren’t available for phone calls or able to continue breastfeeding because of poor maternity leave policies?

How will this change my practice?  First, I think it’s great news that no differences were apparent between groups in terms of breastfeeding difficulties at 24 hours.  In terms of the results at 6 weeks, there might be an association with larger doses of fentanyl.  That reiterates to me the importance of choosing to give the lowest doses possible to achieve maternal comfort in my labour epidurals (always a good idea).  We add fentanyl to bupivacaine (or another local anesthetic) because that way we can achieve more pain relief with less motor block.  Less motor block allows women to push and change positions (and sometimes walk) and potentially avoid forceps or other assisted delivery.   I would love to see another study designed specifically to look at this issue and I would need to see a well-conducted positive study before I gave up or severely restricted fentanyl in epidurals.  The other thing that kind of bothers me is that, although we know some fentanyl is transferred to the fetus during labour, at the doses used in this study, there wasn’t a measurable difference in infant behaviour after birth.  That leaves me to question…what could the possible mechanism be between larger fentanyl doses in labour and early cessation of breastfeeding?  If we can’t think of a biologically plausible mechanism, could this effect have occurred by chance alone?

The association between breastfeeding difficulties perceived by mom and giving up breastfeeding at 6 weeks is just as interesting.  Maybe switching to formula and bottle feeding by 6 weeks has nothing to do with fentanyl at all but tons to do with maternal expectations.  Maybe women who express some dissatisfaction with how nursing is going in the hospital should be offered more intensive lactation consultant help, follow-up and encouragement.  There are so many “maybes” here that another study is warranted to answer this question.  Remember, associations do NOT prove causation…but they should make us sit up and take notice and do some further investigation!

The only other RCT on this subject is by Wilson et al, it was published 5 years later in 2010:

This study comes from the COMET (Comparative Obstetric Mobile Epidural Trial) data.  This trial was done in the late 1990s to investigate the use of lower dose epidurals for labour pain relief and their possible effects on the success of vaginal delivery (btw, they found that the newer, lower dose techniques were NOT associated with greater rates of instrumented or Caesarian delivery).  At the time, they also collected information on breastfeeding.  The paper by Wilson et al looks at four groups of women having their first baby.  Women who requested epidurals were randomized to three groups: a “high” dose (HDI) epidural group (bupivacaine only, 353 women), a low dose (LDI) epidural group (bupivacaine and fentanyl, 350 women) and a combined spinal-epidural (CSE) group (bupivacaine and fentanyl, 351 women).  The fourth group was made up of women who didn’t have an epidural (351 women) who were matched to the trial women by mode of delivery and ethnicity.  Drop out rates over the 12 months of follow-up were similar between groups:

Group	Number   recruited	Number   assessed at 24 h post partum	Number   assessed at 12 mo
HDI	353	349	262
LDI	350	344	263
CSE	351	348	267
Control/   non-Epi	350	344	251

When they looked at the time to initiate breastfeeding, about 2/3rds of women overall initiated breastfeeding which is interesting given that the rate of breastfeeding initiation in the UK where the study was done was reported to be 76%.  The only significant difference between groups was that women from the control group who had IV or IM pethidine (Demerol) were less likely to initiate breastfeeding.  Time to breastfeeding initiation was similar between the groups.  Women were more likely to start breastfeeding if they were non-white and older.

At the 12 month follow-up, there were no differences between the groups in terms of breastfeeding duration.  Although the curves below look slightly different, the confidence intervals overlap and the “differences” aren’t statistically significant.  Does it strike you as funny that they label “still breastfeeding” as “survival?”  I had a good chuckle over that.

 

I think this trial provides good evidence that there is NO effect of modern low dose epidural infusions which include fentanyl on breastfeeding initiation or duration.  Women without labour epidurals did not initiate breastfeeding at greater rates than those with epidurals.

Next, let’s look at this 2006 cohort study by Torvaldsen et. al.

This study was done in Australia.  Women were enrolled in the study if they gave birth to a live infant and were over the age of 16.  Women were recruited who had births in public and private hospitals, a birth center as well as at home.  These women were given questionnaires at 4 days, 8, 16 and 24 weeks after the birth to complete.  1961 women were eligible but only 70% of those approached agreed to participate in the study.  92% of women who started the study actually completed the 24 week questionnaire which is an amazingly low drop-out rate.

33% of the women had epidurals but all of them had pethidine prior to initiation of their epidurals.  Did the hospital have some sort of policy that a woman had to try pethidine prior to allowing an epidural?  This is a very curious finding indeed!

It is encouraging that fully 93% of women were breastfeeding in the first week postpartum and 60% were breastfeeding at 24 weeks.  Of the women who were not breastfeeding in the first week, 48% of them had not planned to breastfeed in the first place.  It is interesting to me that the authors reported factors associated with full breastfeeding vs partial breastfeeding.  Partial breastfeeding in the first postpartum week was associated with increased risk of stopping breastfeeding by week 24 in this study.  Although it seemed that the use of either an epidural or a general anesthetic was associated with partial breastfeeding in the first week, after adjusting for vaginal birth and parity, no statistically significant difference was found…although the authors still stated in their discussion and abstract that a difference was present (once again proving that you can’t just read the abstract).

Women who had an epidural or pethidine were more likely to stop breastfeeding by 24 weeks (6 mo).  Since all women who had an epidural also had pethidine, it’s unclear to me how these two groups were different.  Although they tried to do an analysis of “epidural only” vs “epidural with pethidine,” all of the women who had an epidural without pethidine were women who had planned Caesarian sections.  Since we know that mode of delivery correlates breastfeeding rates I think this analysis adds little value.  We still don’t know if it was the epidural or the pethidine that interfered with breastfeeding.  Judging by the more robust results of the RCT by Wilson et al, I’m inclined to think it was the pethidine…The other difficulty I have  when interpreting this cohort study, is that there was no standardized epidural dosage or solution.

Here’s another prospective cohort study:

This was a retrospective study of 105 women who gave birth in a hospital in Toronto.  To be included in this study you had to have already successfully breastfed an infant and be intending to breastfeed this one too.  This was in an attempt to replicate the results by Beilin et. al.  The primary outcome was breastfeeding cessation at six weeks.  They excluded women who had received opioids or nitrous oxide prior to epidural analgesia.  This study may not be widely generalizable…the breastfeeding rate was 96% and the median maternity leave was 12 months!  In addition, the median length of prior breastfeeding for these women was 11.5 months so they might comprise a group of super-breastfeeders.

At six weeks, four women had stopped breastfeeding.  One of these had received > 150 micrograms of fentanyl while three had received less.  These results are the opposite of Beilin et. al. although the study by Wieczorek et. al. is significantly less robust.  The numbers were very small and it wasn’t randomized.  The most we can say about this study is best said by the authors themselves:

Next, let’s look at the retrospective observational study, Jordan et. al published in BJOG in 2009.

Jordan et. al. is a great example of a data dredge…now there is nothing inherently wrong with a data dredge as long as you interpret the results with caution…They looked at the Cardiff Births survey data from Wales, UK, examining the results of 48 366 births of single infants at term that occurred between 1989 and 1999.  Using regression analysis, they looked at factors associated with partial or complete breastfeeding at 48 hours vs. bottle/ formula feeding.  And they found a ton!!

They found associations with oxytocin (10 U IM used routinely to decrease postpartum hemorrhage), ergotamine, epidurals, social class, induction, C-section, parity, maternal age….The great thing about this paper is that the authors, being astute, mention several times that these associations don’t prove anything and they advocate for studies specifically designed to look at the effect these factors might have on breastfeeding.  Data dredging (retrospective) studies are great for hypothesis generating…not so great for offering conclusions.

I’m not sure why a natural childbirth advocate would take these author’s data out of context and subscribe more importance to it than they themselves do…(tongue firmly in cheek):

“Considering drugs used in labor generally, Jordan, et al (2009) provide some evidence that drug use in labor and birth has an impact on breastfeeding rates at 48 hours postpartum. (Of course, when women have already given up on breastfeeding two days after giving birth, it’s unlikely that they will re-establish breastfeeding later, even though this might be possible.) However, although Jordan et al’s conclusions are fairly clear, we also need to take into account the fact that many anesthesiologists wouldn’t accept these researchers’ conclusions simply because their data is retrospective” (Sylvie Donna, Science and Sensibility).

Another retrospective study (published as a letter only) from Glasgow from V Uppal and SJ Young:

This study retrospectively looked at 13741 deliveries and a woman’s intention to breastfeed at hospital discharge.  5652 women intended to breastfeed while 7668 women intended to exclusively formula feed.  Again, given the low rate of intention to breastfeed overall, I think this population may not be representative of most communities.  Factors that were found to be associated with breastfeeding intention included older maternal age, and being a non-smoker.  Factors associated with choosing to formula feed included a non-white ethnicity, multiparity, opioids during labour and having a Caesarian section.  Epidurals were not associated with breastfeeding at all in this study.  Again, these associations are interesting, but don’t tell us anything about causation…they are simply fodder for future prospective controlled trials.

I’m fairly confident (based on the studies by Beilin and Wilson et. al.) that epidurals do not have an effect on the establishment of breastfeeding or the duration of breastfeeding.  If I’m wrong and such an effect exists, I think it ‘s pretty small (would require a trial with hundreds of women in each arm) and likely to be overcome by social factors and lactation support.

I’m not going to review the basic science articles right now.  I don’t see a compelling reason given that we have good clinical trial evidence that shows epidurals don’t affect breastfeeding significantly.

Unfortunately, I can’t access the following articles at this time and will have to revisit them later:

Gizzo S, Di Gangi S, Saccardi C, Patrelli TS, Paccagnella G, Sansone L, Barbara F, D’Antona D, Nardelli GB.  Epidural Analgesia During Labor: Impact on Delivery Outcome, Neonatal Well-Being, and Early Breastfeeding.  Breastfeed Med. 2011 Dec 13. [Epub ahead of print]

Henderson JJ, Dickinson JE, Evans SF, McDonald SJ, Paech MJ.  Impact of intrapartum epidural analgesia on breast-feeding duration.  Aust N Z J Obstet Gynaecol. 2003 Oct;43(5):372-7.

Just for fun, I read the review articles to see if my reading of the primary literature agreed with these experts.  Both Devroe and Loubert agree with me that current evidence does not support any link between epidurals and breastfeeding.  Reynolds also agrees but she also points out that some of the hospitals where studies were done had policies for women who had epidurals that were not conducive to breastfeeding including separating the women from their infants in the first hours after birth.  That is a significant confounder!  Pandya says that the only well conducted trials don’t support a link while the studies that suggest an association between epidurals and not breastfeeding are over-represented in the media.

Blaming epidurals for lack of breastfeeding success is barking up the wrong tree.  With supportive policies in place in the hospital women who want an epidural to decrease their labour pain will be able to breastfeed with the same success as women who chose “natural” childbirth.

REFERENCES

RCTS

Beilin Y, Bodian CA, Weiser J, Hossain S, Arnold I, Feierman DE, Martin G, Holzman I.  Effect of labor epidural analgesia with and without fentanyl on infant breast-feeding: a prospective, randomized, double-blind study.  Anesthesiology. 2005 Dec;103(6):1211-7.

Wilson MJ, MacArthur C, Cooper GM, Bick D, Moore PA, Shennan A; COMET Study Group UK.  Epidural analgesia and breastfeeding: a randomised controlled trial of epidural techniques with and without fentanyl and a non-epidural comparison group.  Anaesthesia. 2010 Feb;65(2):145-53. Epub 2009 Nov 12.

PROSPECTIVE STUDIES (NON RCT)

Torvaldsen S, Roberts CL, Simpson JM, et al. Intrapartum epidural analgesia and breastfeeding: a prospective cohort study. International Breastfeeding Journal, 2006,Dec11;1:24

RETROSPECTIVE

Jordan S, Emery S, Watkins A, Evans JD, Storey M, Morgan G.  Associations of drugs routinely given in labour with breastfeeding at 48 hours: analysis of the Cardiff Births Survey.  BJOG. 2009 Nov;116(12):1622-9; discussion 1630-2. Epub 2009 Sep 1.

Wieczorek PM, Guest S, Balki M, Shah V, Carvalho JC.  Breastfeeding success rate after vaginal delivery can be high despite the use of epidural fentanyl: an observational cohort study.  Int J Obstet Anesth. 2010 Jul;19(3):273-7. Epub 2010 Jun 2.

Uppal V, Young SJ.  Smoking and ethnic group, not epidural use, determine breast feeding outcome.  Anaesthesia. 2010 Jun;65(6):652. No abstract available.

REVIEWS

Devroe S, De Coster J, Van de Velde M.  Breastfeeding and epidural analgesia during labour.  Curr Opin Anaesthesiol. 2009 Jun;22(3):327-9. Review.

Loubert C, Hinova A, Fernando R.  Update on modern neuraxial analgesia in labour: a review of the literature of the last 5 years.  Anaesthesia. 2011 Mar;66(3):191-212. doi: 10.1111/j.1365-2044.2010.06616.x. Review.

Reynolds F.  The effects of maternal labour analgesia on the fetus.  Best Pract Res Clin Obstet Gynaecol. 2010 Jun;24(3):289-302. Epub 2009 Dec 11. Review.

Pandya ST. Labour analgesia: Recent advances. Indian J Anaesth. 2010 Sep;54(5):400-8.

UNKNOWN

Gizzo S, Di Gangi S, Saccardi C, Patrelli TS, Paccagnella G, Sansone L, Barbara F, D’Antona D, Nardelli GB.  Epidural Analgesia During Labor: Impact on Delivery Outcome, Neonatal Well-Being, and Early Breastfeeding.  Breastfeed Med. 2011 Dec 13. [Epub ahead of print]

Henderson JJ, Dickinson JE, Evans SF, McDonald SJ, Paech MJ.  Impact of intrapartum epidural analgesia on breast-feeding duration.  Aust N Z J Obstet Gynaecol. 2003 Oct;43(5):372-7.

Tags: anesthesia, anesthesiology, breastfeeding, epidurals, evidence based medicine

What really happens during a C-section

I find it absolutely appalling that many childbirth “education” classes don’t cover Caesarian sections (C/S) or gloss over them.  Statistically, 20-30% of women will have an operative birth.  Birth, by the way, is thus defined by the free dictionary, “the emergence and separation of offspring from the body of the mother.”  Birth does not require that you squeeze that baby out of your hoo-hoo in front of a lot of women who are chanting and celebrating their “woo.”

Anyway…

I’ve been in the room for C/S in about 5 different hospitals so far and I’m going to give you a blow-by-blow of  how they go down.  Of course, regional differences exist in terms of procedures and policies, so your C/S may (have been/ be) slightly different.  Some women will have positive experiences and memories of their C/S, some will have negative.  That goes for partners and support people too.

Before you even get to the OR tons of preparation goes on…the room is cleaned and sanitized.  Surgical supplies and instruments are brought up from the “sterile core” and counted.  The anesthesia machine and equipment is checked and drugs are prepared.  Your anesthesiologist will speak with you about your health, your pregnancy and your anesthetic.  This consult can take anywhere from 30 minutes for an elective or semi-urgent C/S  to 30 seconds if it’s a true emergency.

When the star of the show (that’s you mom!) is brought in, you’ll have some monitors placed:

a pulse oximeter to measure your oxygen saturation and heart rate

a blood pressure cuff to measure your blood pressure

three to five ECG patches to monitor your heart

an external fetal heart rate monitor if you are having a C/S for fetal distress

Next, you’ll receive an anesthetic.  For most mom’s that will be a spinal (injection into the back) or via an epidural (a top-up if an epidural is already in place).  Rarely, a general anesthetic will be used.  A spinal or an epidural can be placed with you sitting up and curled forward (like a panda bear) or with you on your side curled in the fetal position.  If you are obese or have scoliosis it is much easier for the anesthesiologist to find the right spot if you are sitting up.  One of the labour and delivery nurses or OR nurses will be in front of you, helping you to get into the best position and supporting you.  The anesthesiologist will wash your back off with antiseptic solution.  This contains alcohol and it feels really really cold.  In my experience, women having contractions will sometimes not notice this step but almost all other women will jump so I warn everybody.  Next, some local anesthetic, like lidocaine, will be used to numb the skin.  After that, a longer needle will be used to find the epidural or spinal space and medication (for a spinal) will be injected or a catheter (for an epidural) will be placed.  Most women won’t feel anything other than a little pressure with this longer needle.  I was one of those women, I didn’t feel anything at all after the numbing medication was used in my skin.

Once the anesthetic is placed, things start to happen rather quickly.  You’ll be helped to lie down on your back.  Accept this help because your legs will start to feel quite weak.  A wedge will be placed under your right side to shift your uterus to the left so it doesn’t compress your large abdominal blood vessels.  Some temporary drapes will be placed while an OR nurse places a urinary catheter.  You might feel like you don’t want a catheter but draining the bladder is an essential step to make the surgery easier for the surgeon and safer for you and the catheter will be removed after the procedure is over.

Next, your abdomen will be washed with antiseptic solution to sterilize the skin and sterile drapes will be placed by the surgeon and his or her assistants.  At this time the anesthesiologist will be working hard to monitor your response to the spinal or epidural injection.

Your support person/ partner is now invited into the OR.  They are given a stool placed by your head where they can hold your hand and the two of you can speak easily.  It’s not common to have more than one support person in the OR because there just isn’t space for more than one person plus the anesthesiologist plus the anesthetic equipment up by your head.  Some hospitals and surgeons will accommodate maternal musical requests.  Some women find it helpful to have a picture of their family, other children or sonogram placed on their chest to look at during the procedure.  No one will accommodate low lighting because the surgeons and operative nurses need to see what they are doing.

The surgeons will test to make sure you are numb before they do anything.  You should expect to feel pressure and pulling sensations but nothing sharp.  They will get down to the uterus and make an incision in it…then they will pull the baby out.  Often a bit of pressure on your upper abdomen/ lower chest helps them with this step and they will warn you when this is about to happen.  Sometimes they are so intent on what they are doing that they forget.  That’s when I take over.  Part of my job is to support you through the procedure and that means explaining what is happening.  That pressure can be pretty intense.  If you’ve been labouring or pushing for a while before the C/S that baby’s head can be wedged pretty far down in your pelvis.

The baby comes out, the cord is clamped and cut, and the baby is handed off to a member of the “baby team” in a way that keeps the OB sterile.  Many OBs will hold the baby up over the drapes so that mom can see it before handing it off.  Your support person is usually invited to look over the drapes so they can see the birth.  Different hospitals have different policies regarding filming parts of the procedure.  Pictures are usually always welcomed.

One great thing is that ORs are now being designed and set up so that the mom can see the baby team and the baby bassinet so that the baby is not out of her site at all from the moment he or she is born to the moment he or she is brought over to the mom.  I think that is a great improvement and really reassuring to moms.  After being checked out, the baby will be swaddled (the ORs are pretty chilly and we don’t want him or her to get too cold) and brought over to mom.  We try to place the baby on mom’s chest and have the dad or other mom or support person help to hold him or her there so that the family can get to know each other.  Sometimes dads fall in love so quickly with their baby that they stand there holding him or her and cooing and forget that mom wants to see and touch the baby too.  That’s also when I’ll step in or on of the OR or LDR nurses will because mom and baby need to get together as soon as possible.  Sometimes the anesthetic monitors and cords make it difficult for mom to get her hands on the baby.  I try to facilitate this as much as possible.  I wish we had reliable cordless monitors.

If mom is doing well, we leave things like this until the end of the procedure or until the baby’s vital signs need to be checked again.  Most anesthesiologists will take some family pictures but sometimes we are busy doing other things to look after you.

Once all the stitches are in place and the dressing is applied, the drapes come down.  Everyone admires the baby.  Mom is moved to a stretcher and the baby is placed on her chest for the ride to the recovery room.  In the recovery room, after vital signs are taken on mom and baby, skin to skin happens as soon as possible and, if mom wants, she can nurse her brand new child.  Unlike with every other surgery we do on adults, we allow a support person to be with mom and baby in the recovery room.

I`ve just re-read what I`ve written and it sounds really dry and sterile…but I have a confession for you.  When a baby is born in the OR I tear up each and every time.  It is beautiful and wonderful and miraculous.  Every single time.

Tags: anesthesiology, birth, c-section, epidural, spinal

Dear Hormones…

Dear Hormones,

I think that you should know that the postpartum period hasn’t been all rainbows and fairy unicorn princesses.

In addition to wobbly mommy-tummy, stretch-marks and boobs that go up and down two or three cup sizes on a daily basis, I’ve had mind-crushing fatigue and vicious mood swings.

It’s taken three months for my perineum to resorb the stiches used to repair a tear and remodel the scar tissue so that normal recreational activities are somewhat enjoyable again.

I wander around covered in fresh (leakage) and curdled (spit-up) boob milk.

I’ve only just been able to readjust my skin care regimine to get rid of both dry flakes and acne at the same time.

But this?

Really?

I’m.  Loosing.  My.  Hair.

In large gobs.

You know in the movies or on TV when someone starts chemotherapy and there is a required shot of them in the shower enjoying the hot water and steam and then they pull their hand away from their head and the camera zooms in on the clump of hair in their hand and then pans up to show the expression on their face?

That’s me.

Okay, I know I’m not on chemotherapy and my problems are more joys than problems and I don’t mean to belittle the courage shown by people who actually have cancer…

But my hair is coming out in large gobs.  My hair, that was never thick or luxurious in any shape or form but baby fine and limp.  My hair, that maybe, if you squinted, might have looked marginally thicker when I was pregnant.

I mean, I love you hormones.  You allowed me to ovulate and carry a baby and produce milk for him…but did you have to tease me with this hair thing?  Having my hair fall out in gobs is really screwing with my already shaky-in-the-light-of-post-partum-body-losing-my-career-for-the-moment self-image.  Hormones, please give me a break before my husband makes me done rubber gloves and excavate the shower drain.

Sincerly,

The Adequate Mother

Tags: hair loss, postpartum, postpartum period, scar tissue

The $22 Natural Rubber Dog Chew Toy

I was five or six months pregnant when we had our first Sophie.

She was lying forgotten and forlorn on the sea wall when we came across her while walking the dog.  The dog, made a bee-line for her which isn’t unusual as the dog makes a bee-line for anything she finds on the ground as she is a connoisseur of ear plugs, band-aids, cigarette butts and, once, a half rotted songbird carcass.

Once I’d wrestled her from the dog I thought I would take her home and boil her and keep her for the baby.  Afterall, Sophie is $22!  The Adequate Father, however, wasn’t going to have any of that.  I’ll admit his point about giving a baby something that had been in a mouth that contained a half-rotted bird carcass might have convinced me.  I’ve since learnt that you aren’t supposed to boil or sterilized Sophie because it screws up the squeaker so The Adequate Father, without even trying, was for the first time in the history of our relationship right at the same time that I was wrong.  Usually, on the few occasions where we have a difference of opinion, he is right while I am more right.

Sophie I ended up back in the jaws of the dog.  She lasted 15 minutes before succumbing to her injuries which included mauling and major dismemberment.  But the damage was done – the dog has figured out that Sophie squeaks. And the dog has a major squeaker fetish.

Sophie II was given to me when I was eight months pregnant by some good friends.  She’s recently come out of her box to play.  My son isn’t too interested in her yet.  He’ll wave her around but she is a bit too big for him to get her into his mouth yet.

But the dog remembers her.

She’s stolen her three times so far.  She waits until I am out of the house and then goes into the bucket of baby toys and fishes her out.  The first time I found poor Sophie covered in dirt and dog hair, lying wounded on the carpet.  Thankfully she was in one piece.  I washed her off and *gasp* gave her back to the baby.  The second time I heard a squeak from the bedroom.  I staged a rescue operation, washed her off again, and *gasp* gave her back to the baby.

The third time, I just caught a flash of something tan and spotted in the dog’s mouth as I walked past the door to our bedroom.  I stopped and turned back to take a look, and there was our happy puppy, sitting on our bed looking all innocent, no Sophie in sight because she had hidden her under my pajama pants.

I have no idea how long Sophie was a prisoner this time.  I am highly suspicious that the dog, who had been lying on the bed for hours, was actually gumming Sophie carefully, avoiding the squeaker so as not to alert me to her transgression.

Smart Dog

I’m not sure what to do now.  Help me out?

The deceptive income of physicians…

Ah yes, those labour epidurals really do have someone laughing all the way to the bank…except it’s the bank, not the anesthesiologist.

 

http://benbrownmd.wordpress.com/

Labour Epidurals and Breastfeeding – lets review the evidence

One of the reasons I decided to start blogging in the first place was this post at Science and Sensibility.  For those that don’t know, Science and Sensibility is the blog-face of Lamaze, and as such, they promote natural childbirth while claiming to be evidence based.  Now, call me old-fashioned, but I don’t think you can be evidence-based if you have an agenda to promote anything at all.  The very nature of promotion is a sell-job and that means you’ve now introduced bias into your review of evidence.  Now, we all have biases, biases aren’t the problem.  The problem is not declaring your biases because that misleads your readers and amplifies the degree to which they perceive you to be objective.

You can read about my biases here.

That post really got a bee in my bonnet for many reasons.  The author, while reviewing the evidence, glosses over the negative prospective randomized trial in favour of focusing on small retrospective trials that support her belief that epidurals interfere with breastfeeding.  She also spends quite a few words discussing basic science studies in order to “prove” that there is a biological basis for believing that epidurals interfere with breastfeeding.  Well, we had a biological belief that Vioxx would be better.  The medical community swallowed that horse-sh*t right up until the scandal broke and class action lawsuits ensued.

Medical research works like this:

1) you establish a biological plausibility for something…to quote Science and Sensibility,

“Epidurals can influence the fluctuation of hormone levels that play an important role in breastfeeding. A study conducted by Handlin et al (2009) found that medical interventions in connection with birth influence the activity of the hypothalamic-pituitary-adrenal axis 2 days after birth. (Adrenal gland activity, which is dependent on pituitary gland activity, which in turn is dependent on the activity of the hypothalamus is affected.) As a result of this influence, hormonal production is likely to be compromised, which will of course affect the success of breastfeeding, which depends on the release of the hormones oxytocin and prolactin.”

2) You form a hypothesis.  She presents the last sentence as a factual conclusion when it is, in actuality, a hypothesis.  She uses strong language, “which will of course affect,” as if anyone who thinks otherwise is an idiot.  Of course it affects…how could you think otherwise.  Of course the sky is blue….What she should say is, “based on this basic science study, it could be possible that medical interventions such as an epidural during labour affect the HPA axis and I wonder if those affects are great and long-lasting enough to affect breastfeeding?”

3) Next, to answer your question (prove or disprove your hypothesis), you need to design a study - either a prospective randomized study (preferred) or a restropsective study with thousands of subjects and a robust statistical model to take into account biases and confounders.  Prospective randomized studies provide a higher level of evidence than any other kind because they are less subject to confounding.

4) If your study design is adequate and your enrolled numbers are large enough then the data you collect will either support or refute your hypothesis.  If your study design sucks and you don’t have enough subjects, your data just confuses everyone and no conclusions can be drawn.

5) The scientific method, relies on reproducibility of results, so for your conclusions to be more robust, other independent (ie conducted by other reserach groups) studies on the same subject need to show the same result before this new information filters down and influences the decisions health care providers and patients make together.  The exception would be a very large prospective randomized multi-center trial with thousands and thousands of patients that has been eagerly awaited by the medical community.

The other thing that really bothered me about this post is that so much of this post is a diatribe against the medical community and that’s a real red flag:

“…the fact that many anesthesiologists wouldn’t accept these researchers’ conclusions simply because their data is retrospective (i.e. it looks back at what happened in the past, and tries to establish causal links); anesthesiologists (like many other specialists) consider prospective randomized studies to be more reliable.”

“Clearly, too, many people involved in the debate have vested interests in continuing to promote epidurals. Caregivers who are unfamiliar (and therefore uncomfortable) supporting ‘noisy’, mobile and ‘demanding’ women (who are laboring without an epidural) are perhaps unlikely to want to change their more convenient practice; anesthetists have their livelihood to think about; drug companies which manufacture drugs such as fentanyl also have enormous profits to lose…”

Here’s the funny thing about evidence – its evidence.  It should be clear and it should speak for itself.  If the evidence for epidurals screwing up breastfeeding really was clear, there would be no need to insert these little snippets suggesting that the medical community is somehow out to get you…that we’re covering up the truth for our personal gain.  The only purpose this paragraph serves is to create distrust and paranoia and an emotional reaction in order to bias the reader towards this woman’s point of view in the absence of the evidence that would convince a critical thinker.

There would also be no need to censor certain commentors that responded to this post and had their opinions on the subject deleted because they reached a different conclusion when they reviewed the evidence.

I can’t accept this woman’s interpetation of the evidence for any link between epidural use and breastfeeding.  She clearly doesn’t “like” medical professionals and she clearly has no idea of the hierarchy of evidence or what sorts of evidence can prove causality and she weights studies that support her point of view heavily while dismissing studies that contradict her beliefs.

I have to review the evidence for myself.  Do epidurals interfere with breastfeeding?  At this point, I have no idea.  We didn’t cover this in our residency.  I am, however, really excited to find out.

I searched pubmed using various combinations of “epidural” and “breastfeeding” and “labour” and then limited things to clinical trials, meta-analysis and reviews.  I included reviews because I should be able to pick up any citations I might have missed.  I’m going to list the citations here.  Please send me any relevant articles that you think I should also review but note that I’m only interested in clinical trials and meta-analysis.  Opinion pieces and editorials need not apply and the same goes for basic science and physiology articles…lets keep the discussion focused on clinical evidence.

Here is the list:

Al-Tamimi Y, Ilett KF, Paech MJ, O’Halloran SJ, Hartmann PE.  Estimation of infant dose and exposure to pethidine and norpethidine via breast milk following patient-controlled epidural pethidine for analgesia post caesarean delivery.  Int J Obstet Anesth. 2011 Apr;20(2):128-34. Epub 2011 Mar 12.

Beilin Y, Bodian CA, Weiser J, Hossain S, Arnold I, Feierman DE, Martin G, Holzman I.  Effect of labor epidural analgesia with and without fentanyl on infant breast-feeding: a prospective, randomized, double-blind study.  Anesthesiology. 2005 Dec;103(6):1211-7.

Chen YM, Li Z, Wang AJ, Wang JM.  [Effect of labor analgesia with ropivacaine on the lactation of paturients].  Zhonghua Fu Chan Ke Za Zhi. 2008 Jul;43(7):502-5. Chinese.

Devroe S, De Coster J, Van de Velde M.  Breastfeeding and epidural analgesia during labour.  Curr Opin Anaesthesiol. 2009 Jun;22(3):327-9. Review.

Gizzo S, Di Gangi S, Saccardi C, Patrelli TS, Paccagnella G, Sansone L, Barbara F, D’Antona D, Nardelli GB.  Epidural Analgesia During Labor: Impact on Delivery Outcome, Neonatal Well-Being, and Early Breastfeeding.  Breastfeed Med. 2011 Dec 13. [Epub ahead of print]

Goma HM, Said RN, El-Ela AM.  Study of the newborn feeding behaviors and fentanyl concentration in colostrum after an analgesic dose of epidural and intravenous fentanyl in cesarean section.  Saudi Med J. 2008 May;29(5):678-82.

Handlin L, Jonas W, Petersson M, Ejdebäck M, Ransjö-Arvidson AB, Nissen E, Uvnäs-Moberg K.  Effects of sucking and skin-to-skin contact on maternal ACTH and cortisol levels during the second day postpartum-influence of epidural analgesia and oxytocin in the perinatal period.  Breastfeed Med. 2009 Dec;4(4):207-20.

Henderson JJ, Dickinson JE, Evans SF, McDonald SJ, Paech MJ.  Impact of intrapartum epidural analgesia on breast-feeding duration.  Aust N Z J Obstet Gynaecol. 2003 Oct;43(5):372-7.

Jordan S, Emery S, Watkins A, Evans JD, Storey M, Morgan G.  Associations of drugs routinely given in labour with breastfeeding at 48 hours: analysis of the Cardiff Births Survey.  BJOG. 2009 Nov;116(12):1622-9; discussion 1630-2. Epub 2009 Sep 1.

Lin SY, Lee JT, Yang CC, Gau ML.  Factors related to milk supply perception in women who underwent cesarean section.  J Nurs Res. 2011 Jun;19(2):94-101.

Loubert C, Hinova A, Fernando R.  Update on modern neuraxial analgesia in labour: a review of the literature of the last 5 years.  Anaesthesia. 2011 Mar;66(3):191-212. doi: 10.1111/j.1365-2044.2010.06616.x. Review.

Reynolds F.  The effects of maternal labour analgesia on the fetus.  Best Pract Res Clin Obstet Gynaecol. 2010 Jun;24(3):289-302. Epub 2009 Dec 11. Review.

Uppal V, Young SJ.  Smoking and ethnic group, not epidural use, determine breast feeding outcome.

Anaesthesia. 2010 Jun;65(6):652. No abstract available.

Wieczorek PM, Guest S, Balki M, Shah V, Carvalho JC.  Breastfeeding success rate after vaginal delivery can be high despite the use of epidural fentanyl: an observational cohort study.  Int J Obstet Anesth. 2010 Jul;19(3):273-7. Epub 2010 Jun 2.

Wilson MJ, MacArthur C, Cooper GM, Bick D, Moore PA, Shennan A; COMET Study Group UK.  Epidural analgesia and breastfeeding: a randomised controlled trial of epidural techniques with and without fentanyl and a non-epidural comparison group.  Anaesthesia. 2010 Feb;65(2):145-53. Epub 2009 Nov 12.

The only citations that I didn’t find that were used in the Science and Sensibility post are:

Camann W. Labor analgesia and breast feeding: avoid parenteral narcotics and provide lactation support. International Journal of Obstetric Anesthesia, 2007, Jul; 16(3):199-201

Pandya ST. Labour analgesia: Recent advances. Indian J Anaesth. 2010 Sep;54(5):400-8.

Torvaldsen S, Roberts CL, Simpson JM, et al. Intrapartum epidural analgesia and breastfeeding: a prospective cohort study. International Breastfeeding Journal, 2006,Dec11;1:24

I’m going to include the last two but the piece by Camann is an editorial so I’m skipping it.

Oh, and if anyone out there can translate the paper in Chinese by Chen et. al. I’d be really grateful.  I am many things, but bilingual is not one of them!

Tags: breastfeeding, epidural, evidence