Greeting to all in this forum.
As the obstetric anaesthetist performing the epidurals, I feel responsibility to correct some Skylark statements and point out important evidence based facts currently available.
In my five year practice, I have met a number of pregnant ladies, who initially refused an epidural (because somebody scared them off), but in agony they suddenly changed their mind and asked for the „last minute epidural“- which did not have enough time to work, thus was not reducing their labour pain. It is perfectly all right if you decide to go natural way, without epidural. For those who are easily coping with pain I would say this is the right way to go (I decided to have mine purely from the proffessional reasons). But there are some of us which are not as "resistant" and and labour makes them overstressed. This is the group I would highly recommend to have an epidural. Please, read this, judge responsively and decide early! It is nothing worse, than leave such a decission to be made in the last minute agony!!!! And believe me, if it was so dangerous, doctors would not be offering it to anyone (especially not to the pregnant!!! = two in one )
These are my comments to some statements you found on the web:
„They are essentially paralyzed“ = not able to move with your limbs.
For the labour epidural, the very low concentration of local anaesthetic is used. This amount of anaesthetic does not cause paralysis. Patient is fully mobile and able to push. In my practice I leave my patients to walk with an epidural and they also can choose a position for labour (except for bath labour - with the risk of infecting the epidural). If Skylark had seen paralysed patient, it must have been either unprofessional labour epidural, or it was not an epidural for labour (it could have been the spinal or the epidural for caesarian section).
” With large doses the patient loses the desire and the ability to bear down and push. This results in an increased use of forceps and vacuum extractions over women having unmedicated deliveries.”
Epidural labor analgesia is not associated with increased rates of instrumented vaginal delivery for dystocia or cesarean delivery. Because epidural reduces agony (state when you are not able to cooperate), you are actually far more cooperative. In my up to date practice I have not seen a single women who lost desire and ability to bear down and push due to epidural analgesia. What we see far more often is exhausted women from long term agony, who does not have enough power to proceed or does not cooperate…the result is forceps or caesarian section.
“Fetal heart rate decelerations was reported as significant risk following the use of epidurals. Babies have higher chance to develop fetal distress after epidural anesthesia”.
The current evidence does not support that babies have higher chance to develop fetal distress after labour epidural analgesia. The opposite is true. Patient satisfaction and neonatal outcome are better after epidural than parenteral opioid analgesia.
The complications of the labour epidural are:
1. Hypotension
"occurs among almost one-third of patients with serious hypotension occurring about 12% of the time”.
Mild lowering of the blood pressure is more the normal side effect than the complication. It is due to reduction of the stress reaction – this effect is used with advantage for labour of mothers with heart or lung disease – to this group of the patients we strongly recommend to have an epidural analgesia for labour (or caesarian section).
What is dangerous is only serious hypotension, especially if it lasts for a long time (it is number one medical priority to recognise it and immediatelly act - we have a number of drugs to conteract that). If the mother was not previously dehydrated or bleeding, serious hypotension should not happen. Both of above conditions should be identified by your doctor and treated far before considering an epidural.
“Maternal hypotension is a major risk for the baby”.
No doubt, it is true. All the facts about oxygen and glucose you have studied are true as well. That is why it is dangerous to deliver outside the hospital. Main reason for serious hypotension is an excessive uncontrolled bleeding, not an epidural!!!
2. Inadequate pain relieve.
” The epidural is generally inadequate 7.1% of the time, leading to supplementation with intravenous pain medication 4.0% of the time and a general anesthetic 3.1% of the time (in one study)”
With 92,9% of success rate? I would say, it is generally adequate
.
Nothing in the world is 100%. The most frequent failure reason is subdural block (not exact position of the catheter, 1:1000)
The large part of inadequate epidurals are “last minute epidurals”, performed too late (up to 15 minutes prior to pushing phase), when there is no time for them to work. Epidural needs 10-15 minutes to start to work.
Having the general anaesthetic for labour is nonsence. You can only have the general anaesthetic for ceasarian section. If you end up having the caesarian, previous epidural is an advantage, because it can be used (with strong anaesthetic solution top up) for all procedure plus postoperative pain relieve. Spinal and epidural anaesthesia for cesarian section is current worldwide standard, because they have lower complication rate than general anaesthesia. General anaesthesia for caesarian is reserved for the emergency caesarian section, where there is no time to perform spinal or epidural.
3. Total spinal = ” When an epidural accidentally turns into a spinal anesthetic:”
1:5000 – 1:50 000. (Compare to: road traffic accident during next year = 1:8000, accidental death at home 1:11 000, death hang gliding per flight 1:80 000) Anyway, if it happens, it must be immediately recognized and appropriate action must be taken. All necessary equipment and personal should be available on place. With accurate treatment this transient state it is fully reversible. Reported deaths are due to inappropriate or late reactions of the incompetent staff.
4. “ Accidental injection of the anesthetic solution into the blood stream can occur and can cause the mother to twitch, have convulsions, or lose of consciousness…The chances of that is about 12-16 in every 1000...”
Toxicity of local anaesthetic (high levels of the drug in the blood) is one of the rare complications related to catheter misplacement. I would oppose the number 12-16 in 1000.
I have performed approx. 500 of labour epidurals and have not seen this complication yet. Anaesthetist is testing for the catheter tip position repeatedly several times during performing an epidural. When epidural works properly, we know that it is not inside the blood vessel. If overdose accidentally happens, we can now very efficiently deal with it. All the equipment and competent staff trained for this situation are present on place continuously.
5. **” Trauma to blood vessels can occur as a result of epidural anesthesia. In one study, bleeding in the spinal column and unintentional placement of the catheter into an artery or vein occurred 0.67% of the time (67 women of every 1000 epidurals).The catheter actually escapes outside of where it is supposed to go 1 to 6% of the time.”
Yes, epidural hemorrhage is on the list as well. It is the risk you have take into account, however, number 67:1000 definitely does not correspond with reality. If you (or your family members) do not suffer from bleeding disorder, and you do not take an anticloting medication (all of this will be checked), than the risk from epidural induced bleeding is minimal.
6 **” The actual dura may be punctured as a result of epidural anesthesia. Because of the large size of the needle used, severe headache may also result. Dural punctures have been found to occur about 1.8%”
That is true, that is the risk you have to take into account. We can treat this complication with „blood patch“. This helps to releave headache in 99% of the cases.
7 **”Backache after an epidural is a common complication. Back pain commonly occurs after epidural anesthesia (18.9% of the time).”
If you suffer for the back pain you will most likely have the back problems during the pregnancy and after the labour - with or without an epidural. I would not wonder, considering the extra weight you carry as a pregnant and limited mobility you have for long time. There is no evidence that epidural increase the likelihood of inducing new back pain. If you are back sufferers I would recommend gravi-Joga (personal experience
).
8**” Uterine contractions can become weaker and less frequent. An oxytocin infusion is then necessary to improve labor and produce good strength contractions Mothers having epidurals have longer labors and have a higher incidence of the use of syntetic oxytocin than mothers having non-medicated deliveries”.
Oxytocin is hormone which is normally produced by your brain during labour. It makes uterus to contract – you would not have a single contraction without it. Synthetic top-up is used routinely in obstetrics – actually I have to say, vast majority of patients ends up getting it - during (to increase contractions) or after the labour (to help deliver placenta or to decrease bleeding).With epidural your labour might take longer (but without pain), but there is no evidence, that it decrease the amount of the endogenous oxytocin (the one released by the brain).
P.S.
To get the most valid of the information from web or medical journals, I strongly advice to sort the articles according to their level of evidence (metaanalysis is the one with very high level of evidence, because it joins results of all aviable studies on the topic): e.g.
Meta-analysis , Effect of Epidural vs Parenteral Opioid Analgesia on the Progress of Labor Stephen H. Halpern, MD; Barbara L. Leighton, MD; Arne Ohlsson, MD; Jon F. R. Barrett, MD; Amy Rice, MD , JAMA. 1998;280:2105-2110. Conclusions.— Epidural labor analgesia is not associated with increased rates of instrumented vaginal delivery for dystocia or cesarean delivery. Patients receiving epidural analgesia have longer labors. Patient satisfaction and neonatal outcome are better after epidural than parenteral opioid analgesia.
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