I stumbled across this site run by the Women’s Health and Education Center which is associated with the UN. And I really really dig it.
Some choice quotes:
“The use of techniques and medications to provide pain relief in obstetrics requires an expert understanding of their effects to ensure the safety of both mother and fetus. Positive attitudes and the need for good medical care should be stressed.”
Positive attitudes? That’s code for YE SHALL DELIVER RELIEF ON DEMAND TO A LABOURING WOMAN AND THOU SHALL NOT JUDGE HER OR CONDEMN HER TO PAIN BECAUSE OF YOUR OWN PERSONAL IDEOLOGY. It’s really sad that in this day and age we have to spell this out…it is really sad that women suffer worldwide in terms of their health because of their gender.
“Maternal mortality relating to anesthesia has reduced 10-fold since the 1950s, largely due to an enhanced appreciation of special maternal risk with anesthesia.”
Anesthesia as a whole has gotten a lot better (safer) since the 1950s. There have been advances in monitoring, technique and in the availability of drugs with better safety profiles. We now provide pain relief in labour and anesthetics for surgical and instrumental delivery with an enviable safety record. Far from the Ina May’s of the world who believe, and like to proselytize, the idea that modern interventions are increasing the maternal mortality rate, physicians have been working diligently to increase the safety and efficacy of their interventions.
I am proud of my colleagues and my specialty. Deaths due to anesthesia are down. By 10x…even though the proportion of women receiving epidurals has increased..even though the global C/S rate today is greater than it was in the 1950s and all those women need an anesthetic. Check out this paper from 2011 in Obstetrics and Gynecology if you are interested. The maternal death rate due to anesthesia from 1991-2002 was 1 per million live births…an improvement of 60% compared to the ten years previous.
I recently read a great anesthesia memoir, Laughing and Crying about Anesthesia, by Dr. Zeitlin. During his career, anesthesia went through tremendous changes and he was able to witness its transformation from inauspicious beginnings into the safe and highly respected specialty it is today. He makes the point that since anesthesia in and of itself isn’t life-saving or – prolonging the way surgery is, patient harm (death and other damage) is unacceptable. I completely agree…and so do my colleagues who will continue to strive to reduce these maternal mortality numbers even further.
I am digressing…more quotes:
“Regional analgesia provides a superior level of pain relief during labor when compared with systemic drugs and, therefore, should be available to all women.”
In Canada, we are failing on this point. We have manpower issues. We have geographic issues. We have resource rationing issues. We have ideological issues (Google Michael Klein) Epidurals aren’t available to all women that want them, particularly those outside of large urban centers, but even those at tertiary and teaching hospitals. Unacceptable? I think so.
The best part of this website, though, are a series of articles about pain management during labour and delivery. They are intended for health care workers that provide obstetrical care (OBs, Family Docs, RNs, Midwives) but they aren’t written in thick medicalese so I think they are a good resource for pregnant women and their partners, doulas and childbirth educators as well. They are fully referenced and evidence based.
Epidural analgesia failures: the technique review, has a great discussion about why epidurals sometimes are less than adequate and what can be done about it. It offers up the reassuring statistic that with enough tinkering 98% of epidurals provide satisfactory pain relief. I think that in the real world, the one I work in, with health care rationing where we don’t have enough anesthesiologists on the ground to provide this tinkering and certainly no DOBA (dedicated obstetrical anesthesia), we fall short of 98%.
On the other hand, I learned that some of my colleagues are so interested in making sure epidurals work for women that they were willing to do studies where they injected stuff into the epidural space of cadavers to analyze how medications spread. Now that is dedication to women’s health and well-being!
From Epidural and Spinal Anesthesia: understanding the facts (which is a great general overview article if you’ve ever been confused about the difference between a spinal an epidural and a combined spinal-epidural plus you want to look at some pretty pictures):
“The American Society of Anesthesiologists (ASA) and the American College of Obstetricians and Gynecologists (ACOG) recommend that third-party payers should not deny reimbursement for regional analgesia and anesthesia because of an absence of other medical indications.”
I would like to see a third-party payer deny pain relief as medically unnecessary in any other context! Seriously. Why are we so cruel to labouring women? And good on the ASA and ACOG for standing up to the insurance companies who really only want to decrease their payouts and increase their profits.
The only beef I have with this article is that it is from 2009 and still includes some (now false) statements about how epidurals before 4-5 cm may increase the risk of C/S…which has been shown to be untrue in two prospective randomized controlled trials. See my post on the subject, here. I guess my recommendation of this website should come with a caveat…check the date the article was published (clearly stated at the bottom of the article) and, as always, discuss your options with your care provider.
What do you think of this website? I was wondering if we could get them to lobby the BC government since BC has an appallingly low epidural rate that is at least partially explained by barriers to access.