Eipdural Anesthesia

A Comment from Dr Bradley last week on my comment about the epidural analgesia issue.

He's right.  The authors did not conclude that their findings supported a rationale for witholding or even re-thinking epidural analgesia. 

That's not quite what I'm saying though … and I suppose that my non-intervention bias is revelaing itself here.

My preference — in my practice of maternity care — as in my practice of medicine in general — is to avoid any intervention unless it's clear that such intervention is necessary and appropriate.

Is an antibiotic intervention appropriate for the treatment of a cold?  Of course not .. but many physicians still do.

When I am involved in maternity care, I always make decisions with my patients — not for them.  The decision to have an epidural is not necessarily risk free.  A few references:

  • Pro-Con forum on epidural analgesia from the Society of Obstetric Anesthesia and Perinatology
  • A Boston University Study demonstrates that children born to mothers who had epidurals  showed poorer performance on the orientation and motor clusters on the Neonatal Behavioral Assessment Scale (NBAS) during the first month of life.  The authors also found that there epidurals were associated with longer labors, greater amounts of oxytocin used, and more instrumentation.
  • This study from Austria which demonstrated  that "The use of EA was associated with a decreased spontaneous delivery rate (50.0 vs. 79.2%), increased forceps delivery rate (30.7 vs. 4.0%) and increased vacuum extraction rate (3.5 vs. 0.7%). The caesarean section rate was not significantly changed in patients with EA (14.4 vs. 13.0%). Fever greater than 38 degrees C during labour and intrapartum haemorrhage exceeding 500 ml were associated with the use of EA."

… but …

These studies don't account for all off the possible confounding variabes (especially the Viennese study .. in which a minority or patients received epidurals.  One could easily argue that the more troublesome deliveries were associated with epidurals.)

We must remind ourselves of the basic rule of correlation: no causality can be inferred.  Does Tick cause Tock?  of course not.  But the r value is 1.

So .. I think that there is enough data to support the concept that there may be increased risk from epidural analgesia.   And this is really all I was saying in my commentary. We should think twice (or thrice!) before intervening in what is usually a normal healthy event.  A "routine" epidural may very well be a component of the obstetric practice of many physicians.  I would argue that this isn't good care, and that the epidural should be presented as an option – with risks, benefits and alternatives carefully presented – just as with all interventions.