I’m saddened by all the misinformation circulating around the web with respect to epidural analgesia/ anesthesia. Most of this information seems to be propagated by individuals who are biased against the technique. My understanding of the technique is quite good – I am, after all, an anesthesiologist. I want to put some information out there to combat all the misinformation and fear-mongering that is occurrng. But before I do, you should understand where I am coming from and what potential biases I might have. If I was giving a talk at a medical conference or to a university class or colleagues at the hospital, I would be required to declare potential sources of bias and I figure that if anyone reads this, they deserve the same. When you search the web for information, just take note of how many people do not declare their biases while, at the same time, they try to educate or inform you!
***DISCLAIMER: Although I have and will make every effort to provide balanced and accurate information individual circumstances may vary and this blog should not, and is not meant to, replace the discussion you should have with your individual healthcare provider.***
POTENTIAL SOURCE OF BIAS 1: I do not receive funding or other means of support from any institution, organization or commercial entity.
(Consider what could happen if I did. Consider Wakefield fabricating research to blame autism on the MMR while he was being paid to develop a competing vaccine. No one would have published his paper or listened to him if he had declared that relationship!)
POTENTIAL SOURCE OF BIAS 2: I am an anesthesiologist.
Anesthesiologists have been accused of “pushing” epidurals (inflating benefits, dismissing or downplaying risks) because of monetary gain. See for example this post on Science and Sensibility that purports to review the literature on regarding a possible association between labour epidural analgesia and breastfeeding. My evaluation of the evidence is much different than Sylvie Donna’s, but more about that later.
I had to laugh when I read this, “Clearly, too, many people involved in the debate have vested interests in continuing to promote epidurals… anesthetists have their livelihood to think about…”
In the first place, I don’t “promote” epidurals. Epidurals are not a consumer product and I don’t advertise or endorse them to patients. If a woman requests help coping with the discomfort of her labour, I discuss an epidural as an option. I make sure that the woman, as part of informed consent, knows her other options (non-pharmacologic, entonox, IV or IM opioids). I have gotten out of the call room bed at 4 A.M. at the request of a woman in labour, trucked down to labour and delivery where, during the discussion it became apparant that she was unsure about proceeding with an epidural. No problem, I said, I’m here and I’ll come back if you decide otherwise. No rush, no pressure.
In case you think I’m some kind of aberration, I haven’t known my colleagues to push epidurals either. There may be an anesthesiologist somewhere that does try to push epidurals on most women, but I haven’t met him or her. Now, there are very special circumstances where it is accepted practice to inform a woman that an epidural is recommended for her particular labour. These would include some women with morbid/ super-morbid obesity, women with some heart or lung diseases and situations where the fetus is at higher risk such as where the ability for emergent conversion to a C-Section has been recommended by the obstetrical care provider. But this is not pushing an epidural…we would still respect a refusal. We might be stressed by that because the alternatives may push our skills to the limit and, in our view, represent a very high level of risk. Some providers might be so stressed that they would refuse to be involved in the case and pass it to a colleague. We can’t force a medical procedure on a competant individual, that’s battery.
In the second place, placement of a lumbar epidural for labour analgesia isn’t lucrative. In Canada, depending on which province you practice in, an anesthesiologist can expect about $100 to place one. Now, if the woman in question has some acute or chronic health concerns (say, pre-eclampsia or coronary artery disease or cystic fibrosis etc) we might get an additional $60 or so to evaluate her ability to cope with labour and anesthetics (perform an anesthetic consult). Most women having babies are pretty healthy, however, so in my experience it’s rare to bill a consult. It takes about 30 minutes to evaluate a woman, have a discussion around consent, place and dose the epidural, and monitor for immediate complications…and that’s if placement is EASY (5 minutes or less). Best case scenario has your labour anesthesiologist earning $200 an hour.
I know that sounds like a lot, but where I live, its about the same as a plumber during the daytime…and way less than a plumber at 4 A.M. Now, I don’t want you to think I’m complaining. I am lucky. I earn a great living and I get to perform a meaningful job looking after patients. I love my job. But not for the money! If I wanted money I would have studied investing and finance or become an entrepreneur. I would have foregone the 13 years of post-secondary education (undergrad, medical, residency) and gotten a real estate licence out of highschool.
Now you could argue that placing an epidural is always more lucrative than not placing an epidural, and you would be right. But I am not thinking about that at 4 A.M. Plus, many of us are on contracts or receive on-call stipends (we get paid by the hospital to stick around overnight) so that whether we actually do anything or not, really won’t affect our bottom line.
POTENTIAL SOURCE OF BIAS 3: I had an epidural for my labour and I loved it.
We are all influenced by our experiences. If I had a horrible experience I might be more inclined to focus on the risks and inconvenciences of an epidural. But I had a great experience and I suppose that may make me for inclined to focus on the benefits and conveniences of an epidural.
So, in following posts I want to attempt to answer the following questions by reviewing the literature:
1) Do epidurals interfere with a woman’s subsequent ability to breastfeed her infant?
2) Do epidurals interfere with a woman’s ability to bond with her infant?
3) Do epidurals slow down labour, lead to oxytocin augmentation or C-section?
4) Do epidurals lead to neurological damage?
And then I’ll attempt to do a nice summary post to tie up any loose ends and address other concerns regarding epidurals.
I welcome comments, but if your comment includes assertions beyond your personal experience and you do not want to be viewed as spouting nonsense from your soapbox, please provide references to scientific papers in peer-reviewed journals. Thanks.