On the 14th of August the Royal Collage of Obstetricians and Gynaecologists of the UK, in collaboration with The Royal College of Midwives and the National Childbirth Trust (or NCT) released a document entitled, “Making sense of commissioning maternity services in England – some issues for clinical commissioning groups to consider.” The founder of the NCT, btw, was inspired to make a difference by the writings of Grantly Dick-Read which should give you an idea of what their overriding philosophy is. The impetus for this document appears to be the upcoming reorganization of the NHS as primary care trusts (PCTs) are decommissioned and replaced with GP-lead clinical commissioning groups (CCGs). Before I go any further, I will admit to not understanding how the NHS is organized and I will also admit that it is a system I have never worked in. I do, however, work in a public system. I am about 99.99999985% certain that there are political factors at work here and 100% certain that I do not appreciate or understand them and that I will be unable to unravel them from my cosy Canadian easy chair. Nevertheless, this document gripped my torso with an icy hand and precipitated a sharp intake of breath followed by a, “WTF?”
Essentially, I would like to openly ask the RCOG, the RCM and the NCT the following question,
ON WHAT DO YOU BASE YOUR RECOMMENDATION THAT THE EPIDURAL RATE BE LOWERED?
See, the document defines “normal” birth:
The consensus statement from the Maternity Care Working Party defines normal birth as “without induction, without the use of instruments, not be caesarean section and without general, spinal or epidural anaesthetic before or during delivery”. It is important to try to increase this rate as well as that of vaginal birth, which includes delivery by forceps and ventouse.
There are many things wrong with this definition and the following statement. Firstly, inductions save the lives of babies…specifically postdates babies and babies that are term when the mom’s waters have broken but labour hasn’t spontaneously begun, among other scenarios. “Instruments” as a class of objects is pretty vague. Is a temperature thermometer an instrument? What about a blood pressure cuff? How about an external doppler for listening to the fetal heart rate? Or by instruments do they mean forceps and vacuum/ ventouse?
I would also like to know why increasing the rate of “normal birth” is held up as a goal in and of itself. Last time I did rotations in obstetrics, inductions, instruments (ie forceps and ventouse), anesthetics and c-sections were used to rescue moms and fetuses that were not tolerating the birth process. They weren’t used for kicks. Holding up an increased rate of “normal birth” as a stand-alone goal without considering health outcomes for mom and baby is, quite frankly, either idiotic or completely useless. Just tack on the following, “while improving or maintaining our currents rates of maternal and perinatal mortality and morbidity,” and I’d be a lot happier. Morbidity in this context meaning things like chorioamnionitis, NICU admissions, hypoxic-ischemic encephalopathy, prolonged length of stay/ hospitalization for mom and/or baby, grade 3 and 4 perineal tears, blood transfusions for post-partum hemorrhage etc etc.
You might wonder why “normal birth” is the goal…well, you don’t have to read too much further to find out:
Avoiding unnecessary interventions in pregnancy and childbirth has been shown to lead to better outcomes for women, quicker recovery, improved satisfaction and saves the NHS money. Every potential caesarean section that is enabled to be a normal birth saves £1200 in tariff price alone. Women experiencing a normal birth are more likely to breastfeed and will require less postnatal care and are less likely to visit their GP with postnatal complications.
I won’t argue that nice normal vaginal births, on the balance of things, probably are easier to recover from and lead to better outcomes for women. But that means a nice normal vaginal birth. Not one of the ridiculously long labours you can read about on Mumsnet where the fetus is OP or sunnyside up and asynclitic with a hand by its face where the mom is denied an epidural, pushes for more than three hours, and has a significant perineal tear. In fact, if it was recognized that labours like this were “abnormal” and interventions were offered, I probably wouldn’t have had such a negative reaction to this document. But the subtext here is that as long as that baby comes out the rear door and mom doesn’t get an epidural that birth was normal so caregivers will be tempted to press on and encourage their patient to stay the course.
This seems to be about money. Specifically, not spending it. Specifically not spending it on things like epidurals and elective or maternal request c-sections.
I find it very disingenuous that epidurals are lumped in with c-sections in terms of leading to poorer outcomes, delayed recovery and lower satisfaction because those things aren’t true of epidurals but the way they’ve phrased things implies so. What is likely to lead to more satisfaction, a woman who requests and epidural in labour and gets one or one that requests one and doesn’t get one? A woman who has an emergency or urgent c-section after hours of labour or one that choses an elective c-section at term before labour begins? I’ll leave you to ponder those scenarios.
But here’s the kicker:
If a trusted GP advises a low risk woman that her care pathway will be midwife led, or suggests to a woman after a caesarean section that VBAC is a good option to explore, she is likely to be more confident about achieving a normal birth outcome.
A VBAC is a normal birth…but an epidural makes your birth abnormal?
There are some possible reasons why the RCOG, RCM and NCT are recommending lowering the epidural rate…most of them aren’t pretty.
1) They believe that epidurals lead to obstetrical complications like slowed labour, instrumental delivery, c-sections, perineal tears and pelvic floor damage.
The balance of evidence does not support increased obstetrical complications with modern labour epidural analgesia. Observational studies in the past did show an increased risk of forcep and vacuum assistance but those studies were done when it was common to use higher concentrations of bupivacaine and the effect disappears at concentrations < 0.125%. Most anesthesiologists use either 0.0625% or 0.08% bupivacaine with a small amount of a synthetic short acting narcotic like fentanyl. We have convincing evidence that epidurals don’t lead to c-sections from randomized studies of early vs late epidural analgesia. Epidurals may slow labour but the effect is pretty minimal and you have to wonder if increasing the first stage by an average of 30 minutes and the second stage by and average of 15 minutes is meaningful to you. You can read my more comprehensive post on the effect of epidurals on labour, complete with citations, here.
With respect to perineal tears and pelvic floor disorders, information is currently conflicting and observational (ie of poor quality). The most recent study I have read does not support epidurals as a risk factor for pelvic floor muscle trauma. I look forward to more data on this subject becoming available. At the moment, it seems like there is an equal chance that epidurals either protect the pelvic floor or put it at risk. Tears and episiotomies are associated with instrumented deliveries and much of the older observational data may be explained by such confounding.
2) They believe that epidurals harm babies (more than other modalities of pain relief).
Epidurals have less effect on neonatal level of consciousness and neurobehavioural scores in the days following birth and less of an effect on breastfeeding compared to IM or IV narcotics. Nitrous oxide (or laughing gas) has few effects postpartum on the neonate. However exposure to it has been associated neuronal apoptosis in fetal and newborn animal anesthetic models and most anesthesiologists have stopped using it in infants. I think that when it comes to labour,the intermittent use of nitrous oxide during contractions probably doesn’t result in an appreciable partial pressure of the gas in the fetal brain. However, we don’t know for sure…for obvious reasons and there is an appreciable amount of nitrous found in umbilical cord blood samples after c-section under general anesthesia when this drug is used.
Clearly non-pharmacologic methods of pain relief can’t cross the placenta and affect the fetal brain…however, ponder this paper and the interesting fact that babies born to mothers who had epidurals had better blood gases (less acidosis) indicating better perfusion and less hypoxic stress than babies born to moms that went “natural.” The thought is that epidurals take away some of the maternal stress response to labour and that increases placental perfusion.
3) They believe non-epidural methods are equivalent or better with respect to the risk-benefit ratio
With respect to benefit (effective pain relief), hands down an epidural wins. Hands down. When it comes to risk-benefit ratio, we’ve already considered obstetrical and fetal complications so lets look at side effects. Both narcotics and laughing gas may result in lightheadedness. Narcotics can cause drowsiness and respiratory depression. Well placed epidurals with dilute solution don’t cause either drowsiness or lightheadedness. They can cause respiratory depression…if you get a too high block or a complete spinal block (< 1/ 20 000). Narcotics and nitrous are associated with nausea and vomiting. Narcotics and epidurals can both cause itch, low blood pressure and urinary retention.
Non-pharmacologic methods of pain relief like a support person/ doula, positional changes, water, massage, visualization and breathing exercises, have few side effects but aren’t effective for many women on their own. Many people disparage epidurals because they remove a woman’s ability to change her position and labour in water but it’s important to realize that you can’t do these things after receiving narcotics or using nitrous either.
The one benefit of an epidural catheter is that it can be topped up for c-section leading to a route to safely establish surgical anesthesia in women at high risk for serious complications of general anesthesia. For more information and an example, you can read my post “the mandatory labour epidural.”
4) they think that labour = pain and that women should expect and tolerate their pain, especially because it is self-limited
I’ve used this example before, but try telling that to someone having a minor ambulatory surgical procedure. They chose to undergo it (she chose to get pregnant), they knew surgery was associated with pain (she knew labour hurts), they know the pain is time-limited (labour, like surgery, doesn’t last forever.) Or what about someone passing a kidney stone? That’s a variation of normal…some people grow stones and some of those stones have to come out. And they hurt when they do so. But if they are small enough to make their way down the ureter they will do so. As they do so, rhythmic spasms of the ureter occur (like rhythmic spasms of the uterus). Why take pain meds when you know it will be over in a day or two? Suck it up! Give birth to your stone “naturally.”
6) They believe that pain in childbirth has some sort of mystical purpose.
Like “teaching you what your body is capable of” or “making you a birth warrior” or “getting down to the root of femininity” or “punishing you for Eve’s transgression.” This may be true for some women. They find a purpose or deeper meaning in childbirth pain and there is nothing wrong with that as long as it is freely chosen and not imposed upon someone. Some people fast for religious reasons. How would you react to them telling you that you must fast too? Some people drop acid in hopes of having a spiritual experience. How would you react if they told you that you must drop acid too? Pushing woman into natural childbirth because you feel the pain has a deeper purpose is profoundly disrespectful. It is up to each woman to decide if her labour pain has a deeper meaning for her or not and not for anyone else to try to layer their value system over her experience.
5) They want to save money.
Here’s the rub. Epidurals cost money. There are equipment and drug costs, anesthesia staffing costs, delayed OR costs (if there is no dedicated anaesthetist for the obstetrical unit and cases in the ORs are delayed while epidurals are placed), staffing costs for monitoring afterwards, costs associated with the limited continuous FHR monitoring that is used for the first 20-30 minutes after the epidural is placed…
The biggest cost savings though, occurs when women give birth at home or in birthing centers of midwifery-led units. In these settings epidurals are not offered. With a homebirth, all the costs of hospitalization are saved. In many birthing centers the minimum stay is only 6 hours post delivery. That saves a ton of money. Decreasing the epidural rate goes hand in hand with increasing the proportion of births that successfully occur in these kinds of units.
The UK birthplace study showed a 40% transfer rate for first time moms attempting a homebirth. 40%. If we want to talk about saving money, how about we talk about discouraging first timers from planning a home birth? Because in the UK two midwives attend a labouring woman at home…and then after transfer you incur all the costs of hospitalization anyway. But such a recommendation doesn’t fit the political climate, now does it?
I wish the authors of the document had better explained their reasoning why they want to decrease the epidural rate (which is already pretty low at 30% amongst woman who planned to give birth in an obstetrical unit according to the Birthplace study). Nevertheless, let’s think about what the implications of this goal are…how exactly can midwives, GPs and OBs decrease the epidural rate? Some possibilities:
1) convince women to give birth at home or in birthing centers where epidurals aren’t available and barriers to getting them are higher (ie they have to request and accomplish a transfer). The document addresses and recommends this.
2) establish restrictive policies: eg epidurals only between 4 and 8 cm or only after a trial of nitrous or narcotic. The NICE guidelines support epidurals on request but feedback from UK moms on Mumsnet suggests that epidural requests are frequently refused before 4 cm and during transition.
3) restrict anesthesia staffing, no provision of dedicated anesthesia coverage for obstetrics. This pretty much ensures that those that ask for an epidural will have to wait until the OR anesthesiologist is available…a time gap that in my working experience could range from 10 minutes to 6-8 hours. The problem with anesthesia resource scarcity like this is that no one is available for stat c-sections. If a stat c-section is called, a second anesthesiologist must be brought in from home and that 20 minute delay could result in permanent death or disability or a c-section under local anesthetic which, I have observed to be a pretty traumatic experience.
4) manufacture a delay: this occurs when the midwife or labour and delivery nurse decides to not call the anesthesiologist when asked or otherwise stalls, lies about the anaesthetist’s availability etc. And yes, sometimes this happens.
5) make the woman feel guilty for asking and use peer pressure to change her mind. This is otherwise known as blaming the woman for her pain. For example the document says, woman may have the
inability to relax and use personal strategies for pain management. All of these contribute to higher risks of complications and intervention.
So what happens when your personal strategy for pain management is an epidural?
The epidural rate keeps going up and up…isn’t this indicative that it has a high degree of acceptance amongst women in childbirth? What do women in the UK actually want? Currently most of them give birth in obstetrical units. The document under discussion suggests this is because they don’t know better…that if they were just better edjumacated they would choose homebirth or midwifery center birth and that this should be the default for healthy pregnant women.
Whilst most pregnant women will be clinically eligible to deliver in a midwife-led unit or at home, the majority still end up giving birth in obstetric units. The new commissioning arrangements provide an opportunity to redress this imbalance by making midwifery-led services the default option for pregnant women.
Has anyone asked the healthy pregnant women what they want?…because my experience has been that quite a few of them (> 50%) want an epidural. In a socialized medical system, does patient preference have no place? Should we all just take what we can get or do we have the right as stakeholders as patients as taxpayers to demand a certain level of care?
In Canada the definition of “normal” birth encompasses both non-pharmacologic and pharmacologic pain relief, including epidurals and spinals. I challenge the British, as the nation that pretty much invented anesthesia and analgesia for childbirth to remember those valuable contributions to labouring women everywhere and reclaim them as part of their national identity. Oh, and it would be nice if either the Obstetric Anaesthetists Association or the Royal College Anaesthetists would comment on this atrocity of a document.