Relief of pain
BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7188.927 (Published 03 April 1999) Cite this as: BMJ 1999;318:927All rapid responses
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Editor, in your 'ABC of labour care - Relief of pain' (BMJ, 3 April)
it is stated in the text that 'Epidurals have some potential
disadvantages', but only two are mentioned. Furthermore, in a box it is
stated that 'Rates of instrumental delivery may be higher among women
using an epidural BECAUSE in the more painful prolonged labours with
malpositions women are more likely to receive epidural analgesia (my
capitals)'. However, a Cochrane review (1) shows that it is the epidural
in itself that prolongs labour, increases the rate of malrotation and
increases the need for operative delivery. Thus the review article seems
to be misleading with respect to important adverse effects.
But is it important to mention all potential and well documented
adverse effects?
The very same week the BMJ published the ABC, a case story was
published in the Danish Medical Journal (2). A pregnant woman had died
following an epidural block and heavy bleeding. She belonged to Jehova's
witnesses and prior to the birth she had declared that she did not wish
any blood transfusions. From an outsiders point of view it seemed
surprising that a Jehova's witness had chosen the most complicated form of
pain relief with a significantly increased risk of several complications
including operative delivery. And even though bleeding was not an outcome
variable in the Cochrane meta-analysis, two observational studies suggest
a significantly increased risk (3). I doubt that a well informed Jehova's
witness would have chosen an epidural.
If patients in general are going to make well informed choices, it is
important that not only documented benefits but also knowledge about
adverse effects are desribed. If the specialist are not thus informed,
they may not be able to inform their patients either.
Ole Olsen, statistician, senior researcher
The Nordic Cochrane Centre
Tagensvej 18B
DK-2200 Copenhagen N
Denmark
e-mail: o.olsen@cochrane.dk
References
1. Howell CJ. Epidural versus non-epidural analgesia for pain relief
in labour (Cochrane Review). In: The Cochrane Library, Issue 1, 1999.
Oxford: Update Software.
2. Cordes M. Klage over behandling af kvinde, som afviste
blodtransfusion efter fødsel med kraftig blødning. Ugeskr Laeger
1999;161:2240-1.
3. Thorp JA, Breedlove G. Epidural Analgesia in Labor: An Evaluation
of Risks and Benefits. Birth;23:63-83.
Competing interests: No competing interests
We read with interest the extract from the ABC of Labour Care1, but
feel that it is too much of an oversimplification to term the technique of
low dose local anaesthetic epidural regimens with epidural opiates as
mobile. Whilst with the majority of regimens in use in the United Kingdom
there is a relative sparing of motor function, this is far from adequate
to provide sufficient power for ambulation, with the emphasis being to
provide adequate analgesia as a primary aim. The anaesthetic aim and
technique is therefore different from that of the truly ambulant or
walking epidural2. Women presenting in established labour will be offered
a technique that leaves them relatively free to move around the bed, but
it is not designed to allow full mobilisation and walking.
Though the aims of the ABC review are clearly worthy, we are reminded
of Einstein's corollary to Occam's Razor. An explanation should be made as
simple as possible, but no simpler.
M A Williams Specialist registrar
R Black Specialist registrar
Shackleton Department of Anaesthesia
Southampton General Hospital
Tremona Road
Southampton SO16 6YD
1 Findley I, Chamberlain G. ABC of Labour Care. Relief of Pain. BMJ
1999; 318: 927-930.
2 Morgan BM. Walking epidurals in labour. Anaesthesia 1995; 50: 839-
840.
Competing interests: No competing interests
Dr. Steele,"a human being should beware how he laughs, for then he
shows all his faults". Emerson, Journals,1836
Competing interests: No competing interests
Sir
Unbiased and contemporaneous accounts of the ever-changing options
for pain relief in labour are scarce indeed and it was a shame that the
ABC of labour care: Relief of pain (BMJ 1999; 318:927-30) did not refer to
the most recent literature on the subjects of backache and epidural pain
relief, and of provision of analgesia.
There is absolutely no prospective evidence of new backache following
epidural insertion for labour analgesia. The paper quoted by the authors
(1) supports this view and contradicts the advice given by Findley and
Chamberlain that prospective mothers should be warned of this
complication. Indeed, a later editorial goes further in distancing
epidural analgesia from the causation of chronic backache (2), in addition
to a prospective study carried out at an earler time (3) which fails to
make a connection between epidural analgesia and new backache. In this
hospital we do not now
discuss backache when obtaining consent for epidural analgesia.
Information on analgesia when provided by staff other than
anaesthetists - for example, by midwives - may lack the contemporaneous
and impartial qualities so important in making informed choice. The
absence of a reference to a recent publication from the Obstetric
Anaesthetists
Association, Pain Relief in Labour, written by anaesthetists, was surely
an omission from Findley and Chamberlain's account.
Dr John Urquhart
Dr Bukky Nafiu
Dr Paul Edgar
Department of Anaesthesia,
West Suffolk Hospital,
Bury St Edmunds,
IP33 2QZ
1 Russell,R.; Dundas,R.;Reynolds,F. Long term backache after
childbirth. BMJ 1996; 312:1384-8.
2 Russell,R.;Reynolds,F. Back pain, pregnancy and childbirth. BMJ
1997;314:1062-3
3 Patel,M.; Fernando,R.; Gill,P.; Urquhart,J.C.; Morgan,B.M. A prospective
study of long term backache after childbirth in primigravidae - the effect
of ambulatory epidural anagesia during labour. International Journal of
Obstetric Anesthesia 1995; 4:187.
Competing interests: No competing interests
Thank you Nikki Lee for making me laugh out loud after an unpleasant
night administering epidurals for labour pain. My distress at realising
that I had been dangerously interfering with the "spiritual changes...that
lead [the mother] to fall in love with the baby" is easily outweighed by
the thought that future nights covering the labour ward will rarely be
disturbed. All I'll need to do in future is ask the midwife not to bother
with those unhelpful vaginal examinations, stop using painful fetal
monitoring and if all else fails to encourage her patient to contemplate
Christie Brinkley's brush with death and run her a bath.
The truth is of course that modern techniques of analgesia for labour
are an enormous advance and in the UK atleast anaesthesia and analgesia
for labour have never been safer. If Nikki Lee doubts this she should
compare recent Reports on Confidential Enquiries into Maternal Deaths in
the United Kingdom (London:HMSO) with those from 20 years ago and perhaps
spend more time on the labour ward.
Competing interests: No competing interests
The only time that pain means things are alright is in labor. Pain in
labor has two important functions: one, to tell the mother that something
is happening, and two, to tell the mother how to move her body to help the
baby be born.
It is disappointing that the authors of this study have ignored the
iatrogenic sources of pain: vaginal exams,continuous fetal monitoring,
confinement to bed, denial of food or drink, and lack of a loving, safe,
and supportive environment where the woman is free to labor in the way
that her body needs. Labor is a time of surrender, not a time to get the
baby out in "x" number of hours. These subtle and not-so subtle pressures
increase a woman's catecholamine levels, tension levels and her pain.
The authors also neglected to mention the use of water in labor as a
fabulous source of relaxation and pain relief.
The actress Christie Brinkley married a man that she had known only a
short time because she had bonded with him intensely during a near-fatal
helicopter crash, They both survived this powerful, spiritually moving
ordeal and the intensity of this event was enough to move them to wed.
Even so with labor. The rhythmic ebb and flow of intense muscular
activity evoke powerful biochemical, emotional, and spiritual changes in
the woman that lead her to falll in love with her baby and do anything to
save its life. Where else does mother love begin, but during an incredibly
intense and powerful process?
Of course this is not to ignore the situations where analgesia and
anesthesia are necessary for relief of sitatuation beyond the ordinary.
However, for about 80 % of women today, the unmedicated labor with the
nurturing of a midwife, will produce the best outcomes: a mother ready to
take in her infant, and a healthy baby ready to meet the world.
There is no anesthesia or analgesia without increasing risk and cost.
I take care of far too many babies and mothers who have been terribly
damaged by anesthesia and resultant birth technology. In the states, the
FDA has issued an advisory to caution about the use of the vacuum
(ventouse), because there have 12 deaths and 9 serious injuries in the
past 4 years. It would be far more effective and cheaper, to make use of
all the evidence supporting the use of midwives and doulas.
Competing interests: No competing interests
Although Chamberlain and Findley's Review of Relief of Pain is clear
and concise, it is unfortunately such an oversimplification that a
valuable opportunity has been missed. Quoting the National Birthday Trust
Survey from 1990 as the most recent reflection of Obstetric Anaesthetic
practice was unhelpful -improved techniques and staffing in the past
decade have led to a significant increase in the use of regional blockade
for labour analgesia and
operative delivery; in this institution 70% of all patients in labour
received a regional block (unpublished, IRB-approved database).
No mention is made of the use of spinal anaesthesia for labour
analgesia - this a major omission,particularly in an review that persists
in referring to the use of combinations of local anaesthetics and opioids
as the "mobile" epidural. Use of this term reinforces the idea that
ambulation is the goal of the technique, rather than analgesia, with
preservation of motor and proprioceptive function. Whilst these aims are
similar, they are not the same.
It would also have been helpful in this regard to mention the use of
newer local anaesthetic agents such as ropivicaine, which may go a long
way to reducing the incidence of motor block.
Finally the authors do not explain the basis of their claim that
"regional anaesthesia is about eight times safer(than general
anaesthesia)". While few obstetric anaesthetists would disagree that
regional anaesthesia is preferable,the risks of well- conducted general
anaesthesia are not as
great as suggested, even in the obstetric patient. The only death directly
attributable to anaesthesia in the last Confidential Enquiry into Maternal
Deaths was associated with combined spinal/epidural anaesthesia(1).
I regret that an opportunity to review much of the innovative work
that has alterred the nature and
extent of obstetric anaesthesia - and has certainly made it my own area of
specialist interest - has been missed.
Reference: 1. Why Mothers Die - Report on Confiential Enquiries into
Maternal Deaths in the United Kingdom 1994 - 1996. Department of Health.
London; 1998
Competing interests: No competing interests
Bravo Dr Bratt
The deficiencies in the original article have been adequately
highlighted but Dr Bratt was eloquent in his appraisal of the junior
anaesthetist's jibes.
The people who spend six to nine months caring for pregnant women and the
women themselves are those who really understand childbirth....and the
true boundaries of art and science..not those who waltz in and out in
fifteen minutes.
Competing interests: No competing interests