JOINT NEWS RELEASE
FOR IMMEDIATE RELEASE
Dangerous Misinformation Regarding Epidurals
and Cesareans Sections
Edmonton and Calgary (June 24, 2005) – The
rate of epidural anesthesia use in first-time mothers in
many urban Alberta hospitals is passing the 75 percent mark,
according to recent Alberta Perinatal Health Audit Data statistics,
and consumer groups such as ASAC, Birth Unlimited, Edmonton
VBAC Support Association/ICAN of Edmonton, and Calgary VBAC
Support believe that this is contributing to an increase
in cesarean section rates.
“Epidurals do increase the need for cesarean
section,” says Tracy Kennedy, President of the Association
for Safe Alternatives in Childbirth (ASAC) - publisher of Birth
Issues magazine in Edmonton . “Standard medical care
is to apply labour induction drugs after an epidural is inserted
because uterine contractions tend to slow down. Women with
epidurals also require careful monitoring because of the
potential anesthesia-related complications to them and their
babies.”
A wave of dangerous misinformation is sweeping
through birthing hospitals in Alberta . Consumer groups such
as ASAC, Birth Unlimited, Edmonton VBAC Support and Calgary
VBAC Support, are concerned that, because of one study, pregnant
women and caregivers will believe that using epidural anesthesia
during labour does not increase the chances of a cesarean
section. Many previous studies have shown that epidurals
also increase the likelihood of tears, forceps delivery,
and vacuum extraction.
The results of this particular study, titled “Effect
of Labor Pain Medication Timing on Cesarean Section,” were
published in the New England Journal of Medicine in
February 2005. The article suggested that the use of epidurals
in early or late labour does not affect cesarean rates, an
idea that has since been widely circulated through North
American media and birthing hospitals. According to consumer
groups, the cesarean rate will further increase because of
new medical guidelines issued by the SOGC, Society of Obstetricians
and Gynaecologists of Canada, recommending blanket cesarean
policies for certain pregnancy situations, such as for breech
babies, and policies supporting repeat cesareans over vaginal
birth after cesarean (VBAC).
“Cesarean section rates keep climbing,
and the excessive use of epidurals is one of the key reasons,” says
Shannon Beckett, President of the Edmonton VBAC (Vaginal
Birth After Cesarean) Support Association, a chapter of the
International Cesarean Awareness Network (ICAN). “Anesthesia
dulls the woman's capacity to labour, to walk and to change
positions as needed. Failure to progress in labour is one
of the most common reasons for performing cesareans in first
time mothers, which is the group that uses epidurals the
most.”
“One good thing about this epidural controversy
is that pregnant women will be thinking harder about avoiding
cesarean sections,” says Raina Gardner, Vice President of
Birth Unlimited in Calgary . “A cesarean is major abdominal
surgery that carries health risks to mother and baby, including
long-term injury and death, which is why they should be reserved
for emergencies only. What we are experiencing in Alberta
is cesareans taking place for less than urgent circumstances,
meaning that the majority are preventable or unnecessary.”
“Many women that give birth today in Alberta
plan carefully how to avoid an epidural,” says Shannon Peddlesden,
of Calgary VBAC (Vaginal Birth After Cesarean) Support. “In
order to cope with the intensity of the labour contractions,
these women hire doulas for labour support, and midwives
for birthing at home or in hospital; in addition, they use
showers and pools, hypnosis, birthing balls and deep breathing.
Unfortunately, standard hospital care is to offer pain relief
drugs which is part of normal medical training, instead of
using the many creative and low-risk ways available to help
women cope.”
The epidural study compared an intravenous
or intramuscular narcotic injection versus an epidural, but
it did not compare cesarean rates for drug-free deliveries.
In the study women with epidurals had their labour contractions
accelerated with induction drugs, powerful chemicals that
also carry health risks. A response to this study by the
Maternity Center Association in New York City can be found
at www.maternitywise.org .
For interviews or more information, please
contact:
All of the above groups are consumer-run
non-profit organizations whose main goal is to offer informed
choices of care in pregnancy, childbirth and parenting to
Albertans. These Associations all agree that childbirth is
a natural biological process, and a profound rite of passage
for women and their families. They believe that the great
majority of births, when uninterrupted by routine medical
procedures, can be safe and uneventful.
BACKGROUNDER
Response to Epidural Study by Maternity
Center Association in New York , New York
Source: http://www.maternitywise.org/home.html
Effect of Labor Pain Medication Timing on Cesarean Section: New England Journal
of Medicine Study, February 2005
Summary, Analysis, Concerns
Maternity Wise © visitors are hearing about a new study about the timing
of labor pain medication. Many media reports are providing misleading coverage.
The Maternity Center Association has prepared the following information to
help visitors interpret this study, which Cynthia Wong and colleagues published
in the New England Journal of Medicine on February 17, 2005.
Please see the Maternity Center Association's clear, simple advice for women
about pain relief (See http://www.maternitywise.org/nejmlaborpainadvice.html ).
What did the February 2005 study
do?
The focus of the new study was on how to use the intervention, rather than
whether to use it. The researchers looked at two approaches to regional analgesia
, which refers to giving pain medications within the spinal column. Their objective
was to understand whether waiting until later in labor could offer benefits,
including reduced likelihood of cesarean section.
Only healthy women participated in the study. Each woman who agreed to participate
was assigned by chance to one of two study groups:
- "early" regional
group got one type of regional analgesia
before their cervix had dilated to 4 centimeters, then
later got another type of regional analgesia
- "late" regional
group got pain medication by injection into
the muscle and by intravenous drip first, and regional
analgesia later, generally after their cervix had dilated
to 4 or more centimeters
The early regional group had two
types of regional analgesia. Early in labor, women in this
group had spinal analgesia , which is injected
into the fluid that surrounds the spinal cord and given just
once. When they asked for more pain relief, they had epidural
analgesia . An epidural is when
pain medication is delivered through a small tube ( catheter
) into the epidural space just inside the tough outer membrane
covering the spinal cord. This multi-stage technique, which
is not widely available in U.S. maternity settings, is sometimes
called combined spinal-epidural analgesia .
The late regional group received a narcotic, hydromorphone ,
through an injection into the muscle and through an intravenous drip early
in labor, followed later in labor with epidural analgesia ,
regional medication through a tube into the epidural space.
Did the study do a good job measuring
differences between earlier and later regional analgesia?
Unfortunately, it is difficult to answer The main question, whether delaying
regional analgesia reduced the likelihood of cesarean section, for two reasons.
First, other things could have influenced the results:
- The late group received hydromorphone ,
a powerful drug that influenced just this group
- over 90% of mothers in both groups received synthetic
oxytocin , a drug that intensifies contractions
of the uterus, beginning in most cases early in labor;
this could reduce the use of cesarean section in both
groups and lead to misleading results about effects of
regional analgesia
Second, the combined spinal-epidural
technique is not widely used in the United States and differs
in fundamental respects from epidural analgesia. We do not
know if results of the combined technique apply to the more
common use of epidural alone.
Have other studies found that
delaying regional analgesia lowers risk for cesarean section?
Lieberman and O'Donoghue (2002) carried out a rigorous systematic review (See http://www.maternitywise.org/mw/ebmc2.html )
of the best available research to understand whether delaying use of epidural
until later in labor reduced the likelihood of cesarean birth. They concluded
that such a delay may lead to fewer cesareans, but that existing research could
not give a clear answer.
Does the study show that epidurals
are safe?
No. Women in both groups had epidural analgesia later in labor. The study did
not compare groups that did and did not have this type of pain relief. Therefore, this
study sheds no light on the safety or effectiveness of epidurals. It is wrong
to conclude from this study that epidurals are "safe".
What is the best evidence about
the safety of epidural analgesia?
There is ample rigorous research showing that epidurals have many adverse consequences
, including systematic reviews from the Maternity Center Association's “The
Nature and Management of Labour Pain”project (See http://maternitywise.org/prof/pain/ ,
published in American Journal of Obstetrics and Gynecology , May 2002). It
is important that all pregnant women understand pros and cons of epidurals
and other methods of labour and pain relief (See http://maternitywise.org/mw/topics/pain/ ).
In a systematic review of adverse effects of epidural analgesia, Lieberman
and O'Donoghue (2002) found that epidurals increase:
- risk of tachycardia (abnormally rapid heart beat) in
the fetus
- length of pushing phase of labor
- use of vaccum extraction or forceps
- risk of serious perineal tears into the anal muscle in
mothers
- risk of fever in mothers
- evaluation of newborns for infection, and early separation
of mothers and babies
- provision of antibiotics to newborns.
This review also found that mothers with
epidural were less likely to have a spontaneous birth (with
neither cesarean nor use of vacuum extraction or forceps),
and that their babies scored worse on Brazelton Neonatal
Behavioral Assessment Scale.
A systematic review by Mayberry and colleagues (2002) looked at the impact
of epidurals on the labor experience, and found that epidurals increase likelihood
of:
- trouble urinating
- sedation
- low blood pressure
- immobility, even when encouraged to move about
- itching.
Mayberry and colleagues found that use
of epidural analgesia was associated with use of many other
interventions to monitor, prevent or treat epidural side
effects. This regional analgesia technique involved routine
use of electronic fetal monitoring, intravenous drip, and
frequent blood pressure monitoring, and increased the likelihood
that mothers would have other labor interventions, such as
synthetic oxytocin , bladder catheters, and drugs for low
blood pressure (2002).
Does the February 2005 study show
that epidurals do not increase risk for cesarean section?
No. Because women in both groups had epidurals, this study sheds no
light on whether an epidural increases risk for cesarean section. Lieberman
and O'Donogue's systematic review of randomized controlled trials and observational
research looked at the best available studies for answering this question and
concluded that available studies did not permit a clear answer (2002). For
now, the best we can say is that having an epidural may increase risk for cesarean
section.
What are some concerns about the
quality of care provided in this study?
The Maternity Center Association has concerns about the quality of care that
participants in this study received. Due to these concerns, to difficulty understanding
the impact of hydromorphone and synthetic oxytocin on study results, and to
limited use of combined spinal-epidural technique, this study should
not serve as a model for the care of healthy birthing women.
Nearly all of the healthy study participants (early group: 92%, late group:
95%) received synthetic oxytocin . For most, use of this drug began early in
labor. Due to adverse effects associated with synthetic oxytocin (See http://www.kingpharm.com/uploads/pdf_inserts/Pitocin_PI.pdf )
its routine use in healthy women is not appropriate.
Despite this near-universal "stimulation" of labor and inclusion
of only healthy women, over one-third in both groups experienced either surgical
delivery cesarean section (See http://maternitywise.org/mw/topics/cesarean/ ).
The "late" group received hydromorphone (trade name Dilaudid®),
a narcotic that is stronger, quicker-acting, and more sedating than morphine.
The Food and Drug Administration "label" or guidelines for hydromorphone
in the Physician's Desk Reference (PDR), states that it is contraindicated
(not to be used) for labor and birth.
Drug-free help with pain relief (for example, continuous supportive care in
labor and use of tubs, showers and "birth balls") was not offered
to the "late" group, yet these options have good safety profiles
and many who use them give high ratings for pain relief. Providing continuous
labor support would reflect a serious commitment to limiting use of cesarean
section in healthy women, as a systematic review on effects of continuous labor
support has found that, across many higher-quality studies, the presence of
a companion with an exclusive focus on labor support reduced risk of cesarean
by 26%.
What are additional concerns about
this study?
The report opens by describing current policy of the American College of Obstetricians
and Gynecologists (ACOG) on timing of epidurals. ACOG recommends not providing
epidurals until a woman's cervix has dilated to 4 or 5 centimeters, as earlier
use of epidurals may increase risk of cesarean section. The authors discuss
their concern that this policy may prevent women from access to effective pain
relief in early labor, and hypothesize that initiating combined spinal-epidural
in early labor would not increase risk of cesarean. Because the policy addresses
epidural analgesia, the new study does not evaluate the wisdom of this policy.
The study was not seriously set up to measure differences between the groups.
The bar for detecting differences was set so high as to ensure that the conclusion
would be: no difference in cesarean rates between the 2 groups. The researchers
enrolled just enough women in the study to be able to detect an improbable
difference between groups of 50 percent or more in the rate of cesarean delivery.
Such dramatic results are not achieved with a single intervention, especially
one in which both groups received such similar treatment (e.g., epidurals,
synthetic oxytocin). The study was not set up to detect differences in cesarean
rates that might be less than 50%, which the authors trivialize as "small".
A casual glance at Tables 1 and 2 could lead people to assume that this study
compared having regional analgesia to not having it. In these tables the study
groups are labeled as regional versus injection/intravenous groups rather than
early versus later regional analgesia. The article does not provide specific
numbers that clarify that virtually all women in both groups had epidurals.
Similarly, the authors note that although epidural has been associated with
increased use of synthetic oxytocin, this study found no differences in groups;
in fact, the study cannot shed light on whether epidural involved increased
used of labor stimulation as both groups received epidurals.
Media coverage of the study has been
confusing and could lead many to conclude erroneously that
the study could in fact shed light on the safety of epidural
and whether it is associated with cesareans. Some headlines
erroneously state that the study shows that epidural is
not associated with increased risk of cesarean and is a
safe option for laboring women, without qualification.
The study was not endorsed and funded by an external group, such as the National
Institutes of Health, but was supported by the department of anesthesiology
with which most authors were affiliated.
The sweeping conclusion at the
end of the discussion section goes far beyond what can
be determined from the present study:
"In summary, the results of this randomized trial suggest that nulliparous
women in spontaneous labor or with spontaneous rupture of membranes who request
pain relief early in labor can receive neuraxial [regional] analgesia at this
time without adverse consequences." (p. 665). This is misleading
in three major respects:
- The study was not designed to measure whether
there are adverse effects with receiving regional anesthesia ,
which in fact have been well-documented.
- Other treatment that study participants received makes
it difficult to understand the impact of delaying
regional analgesia.
- It is wrong to apply results of this experience
with early spinal injections to regional analgesia generally,
including early use of epidurals.
You might be interested in other
labor pain resources on MCA's website:
- Download the Executive Summary (PDF) from MCA's "The
Nature and Management of Labor Pain" project
(best evidence on many labor pain topics).
- Learn about MCA's Labor Pain Initiative, which clarifies
current knowledge about labor pain and methods for relieving
it through the evidence-based framework and systematic
reviews.
- See evidence-based guidance for pregnant women, How will
I cope with labor pain?
- Read labor pain results from Listening to Mothers: Report
of the First National U.S. Survey of Women's Childbearing
Experiences (PDF, see pages numbered 19-23).
References
Lieberman E, O'Donoghue C. Unintended effects of epidural analgesia during
labor: a systematic review. Am J Obstet Gynecol 2002; 186:S31-68.
Mayberry LJ, Clemmens D, De A. Epidural analgesia side effects, co-interventions,
and care of women during childbirth: a systematic review. Am J Obstet Gynecol
2002; 86:S81-93.
Wong CA , Scavone BM, Peaceman AM, McCarthy RJ, Sullivan JT, Diaz NT et al.
The risk of cesarean delivery with neuraxial analgesia given early versus late
in labor. N Engl J Med 2005; 352:655-65.
Most recent page update: May 2005
©2005 Maternity Center Association. All Rights Reserved.
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