Epidurals – Part I Introduction and Declaration of Bias

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.

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10 comments

  1. Just found this site and am loving what I’m reading so far. I’d like to list you on my blogroll, if that’s ok? I do the SquintMom blog (“resources for evidence-based parenting”).

    1. Please do…thanks for the feedback!

  2. Regina · · Reply

    I just came across you blog this morning. I enjoy your writing style. In response to your comment about the article in Science and Sensibility I thought I’d post this link http://www.utahmaternityinsurance.org/ (it’s the quickest source I could find but I’m sure an indepth search could find more sites of reference) for you: it tells the average cost of epidural in Utah, USA. It is much more that $200. Perhaps financial push is different in Canada with your health care system? Certainly, not every provider is pushy, not even most, but MANY are. In my experience here, generally, it’s nurses and OB’s (some CNM’s) who are pushy, not the “magic man”. Here, it’s the other medical staff that push and push and push for an epidural; anyway, that’s how it comes across due to the requirement to assess their pain level hourly and suggest pain management. I know of a few nurses who have lied to patients about there cervical dilation so they would get an epidural because those nurses are uncomfortable with unmedicated births. Surely they do not represent the majority, but those kind of providers to exist. We have an exceptionally high epidural rate where I live, in fact, it is often touted/joked that women will be hooking themselves up as soon as they hit the nine month mark. Some of the nurses even pit one practitioner against another saying, “If you want a light one you better get in now because our nice anesthesiologist is at the end of his shift. The other guy gives heavy ones, so if you’re thinking may want an epidural but a light one you’ll need to get it in the next 20-30 minutes.” I have heard that statement more times than I can count as a doula. It’s frustrating because it’s manipulating to the mother and it’s wrong to lie about the character of each anesthesiologist. The anesthesiologists and the nurse anesthetists are equally skilled, talented, and compassionate here. That’s my long, long winded (typed) way of saying: in my area, it does cost more that the price you quoted for epidural placement; and, the anesthesiologists aren’t the ones we find pushy, it’s our nurses–here in my area. 🙂

    1. That link was interesting reading…thanks.

      What I quoted is what anesthesiologists get paid in Canada. This is public information that can be found on the websites of public insurers in Canada (eg OHIP in Ontario). The fee a patient might be charged in the US for an epidural will most likely vary depending on the hospital and include everything related to the epidural: anesthesiolgist’s fee, equipment, medications and the cost of nursing monitoring…I haven’t worked in the US but from colleagues who have, my understanding is that they nickle and dime the patient for everything, including every last piece of gauze that is opened but not used.

      It would be interesting to know what sort of profit margin for the hospital is built into it’s fee schedule.

  3. I guess my question is whether anesthesiologists are paid on a per-procedure basis. I would guess that, like most physicians, they’re salaried, but I don’t know for sure and would like some light shed on this. If they’re not paid per-procedure, it doesn’t matter what an epidural costs; they’re making the same either way.

    1. Some anesthesiologists are fee for service…some are salaried. The busier and more academic the hospital, the more likely they are to be salaried and, interestingly, the more likely the epidural rate is to be high.

      We don’t have nurse anesthesiologists in Canada. My understanding is that it is within their scope of practice in the US to place epidurals for labour. They are all salaried.

  4. Nichole · · Reply

    The thought of having an epidural has always really scared me. I’m looking forward to reading this series.

  5. Carly · · Reply

    I laughed pretty hard at your bias #3. I look forward to reading your posts!

  6. The internet misses you, adequatemother! Thanks for this incredibly useful resource.

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