Pregnancy Support Group

I'm not worried about the epidural,
I've discussed it with my doctor and he assures me I have
a better chance of getting in my car and breaking both my legs
than an epidural seriously hurting me.

I trust him, and I'm not going to fret over it cause if
I do its just going to worry me crazy. I'll just take my chances
with it I guess. Rather that then suffer through labor, I want
it to be a semi-enjoyable experience that I dont regret (=

I do not agree with anyone telling you what to do, and I certainly am not saying women should birth without an epi, but if you are worried about labour it really is not that bad. I will be having a natural birth again, so you could find it is enjoyable without the drugs!! Each to their own though, the main thing is safe arrival of our babies and a good experience for mum & dad!! x

The results in the Canadian Family Physician and the basis for their analysis was a retrospective trial. That is instead of designing a study to specifically evaluate epidurals effect on c-section rate they just looked back at their records and compared results in those who had epidurals and those that did not. I realize that understanding how to evaluate which scientific study is stronger requires knoweledge of the scientific research process. The danger in using retrospective analysis is that many other variables that effect c-section rate are not evaluated. In other words, were there significant differences between the two groups that made the women in the epidural group more likely to get a c-section independent of the epidural? Where the women in the two groups given other treatments that were different from each other that could effect c-section rate? Where the women in the epidural group and non-epidural group matched by wether they presented in labor or were being induced?Also, studies have found women who have abnormal labor patterns to start with experience more pain and are more likely to request an epidural. Women with abnormal labor patterns are also more likely to have a c-section. Therefore, more accurate scientific data is obtained when analyzed on an intent to treat basis. Another words did the woman want an epidural or did something about a change in her labor cause her to change her mind and could that change in labor also increase her risk of c-section independent of the epidural. Also, the retrospective analysis don't mention what medication and dose was used in the epidural was this consistent throughout all people getting epidurals. The most reliable studies are randomized controlled trials. This is where women who are matched according to other characteristics that could influence c-section rate are separated to two groups epidural and non-epidural. The management of their labor is standardized. Then results compared. Because it is difficult to navigate these studies, you should consult an individual qualified to explain these differences to you. I think that is your anesthesiologist.

I do not want to get into a back and forth of research in epidurals with Franny. But like I said ask your anesthesiologist about what the most recent clinical trials say about c-section rates (these were independent of the studies found in the meta analysis evaluated in the article mentioned by Franny). Also, ask about the most recent research in regards to effect on labor rate. Ask if the studies show that there is any difference in c-section rate or labor rate if the epidural is placed early (latent phase) vs later (active phase).

Another thing that may be helpful for you all to realize as you look at these studies and how they relate to you is that all epidurals are not the same. What I mean by that is that an epidural is just a plastic tube (all of them are that). The effect that you get from an epidural depends on what medication and dose that you put through it based on this you can get dramatically different results. Epidural analgesia has greatly improved throughout the years. Earlier studies were often performed with types of local and doses of local that tended to produce a greater motor block. No surprise their effect on labor was different then the effect when the doses were changed. When I evaluate a scientific study on epidurals, an important thing I look at is what medication and what dose did they use. This allows me to evaluate what the results of the study mean for my patients and how I practice. This is yet another reason why you should consult with your anesthesiologist. They know what their epidural plan is and what the evidence says about that particular plan.

I hope that this information is helpful and informative to each of you. I adamantly believe that this is a personal choice and you should not feel pressured into or scared out of getting one. I hope the information contained in this post helps you in determining how to obtain objective accurate information that will allow you to make an informed decision. Again, best of luck to each of you regardless of which birth plan you decide is right for you.

Actually, the Canadian Family Physician is a review of the meta-analysis mentioned by Kara.

This is a link summarizing the results of the Cochrane meta-analysis, and concluding that c-sections are not influenced by epidural anaesthesia:
http://anesthesiologyinfo.com/arti...

The Editorial in Canadian Family Physician (http://www.cfpc.ca/cfp/2006/Apr/vol52-apr-editorials-2.asp) actually reviewed the Cochrane meta-analysis and concluded that the Cochrane meta-analysis has serious flaws. It is actually a review of the methodology of the Cochrane meta-analysis.

Upon analyzing the Cochrane meta-analysis, the author, Dr Klein, Professor Emeritus of Family Practice and Pediatrics at the University of British Columbia in Vancouver and is certified in pediatrics, neonatal-perinatal medicine, and family medicine, concludes that the Cochrane meta-analysis, which is flawed, has actually inadvertently resulted in the increased use of epidurals, resulting in "collateral damage"..because sometimes, epidurals are given before the active phase of labour. And when that happens, having an epidural more than doubles the probability of receiving a CS.

This is what Professor Klein writes:

"Collateral damage

The Cochrane meta-analysis of EA has inadvertently increased use of EA, and has therefore increased continuous electronic fetal monitoring; kept more women in bed (usually with an intravenous drip); and led to more instrumentation, more perineal trauma, an increase in the CS rate, and, likely, more feelings of failure among mothers. It will also lead, because of the increase in CS, to an increase in problems with placentas in future pregnancies (previa, accreta, percreta, abruption),19 infertility,20 and ectopic pregnancies.19 This is unexpected collateral damage that contributes to overuse of technology during childbirth. It has even led some to suggest that, since childbirth is already so unnatural, CS on request is not such an unreasonable idea—a surgical solution for a non-surgical problem.21-23

The 2005 Cochrane meta-analysis24 was augmented by 3 new studies,25-27 2 of which had such low baseline rates of CS that the effect of EA on CS could never be demonstrated.25,26 One study25 evaluated the combined spinal-epidural method, similar to Wong et al,17 but suffered from very high crossover rates between trial groups, and 2 studies randomized patients before 4-cm dilation.26,27 When these studies are appropriately removed from the new meta-analysis, the result remains exactly the same: early EA more than doubles the CS rate. Surprisingly, the new Cochrane review provided extensive sensitivity analyses for many issues but none by timing of EA administration.

Conclusion

Contrary to the conclusion of the Cochrane meta-analysis of EA compared with narcotic analgesia, EA given before the active phase of labour more than doubles the probability of receiving a CS. If given in the active phase of labour, EA does not increase rates of CS. Meta-analysis can be helpful and timesaving for busy practitioners, but we need to be vigilant about which studies get into the meta-analyses and ask ourselves if they make clinical sense. And, unfortunately, we need to continue to read the individual studies that make up meta-analyses—especially if they are likely to actually change practice—to determine whether study conditions represent our clinical reality."

I agree totally with kara that nobody should scare you into having an epidural, or scare you into not having one.

It is something you have to look into, learn about, and discuss with your doctors....ideally BEFORE you end up going in to deliver. Discuss the advantages and risks of having an epidural, then write it up in your birth plan, so your wishes are respected.

I think that ruth is very brave for having had an unmedicated birth...not many of us, myself included, have had that type of courage!

It is also an option for you to include in your birth plan something like "No epidural if possible"...which leaves it open.

Once in labour, you will see how well or not you can tolerate the pain, and decide. Especially if it is your first one, labour will usually be more than long enough for you to get an epidural safely into place if you do decide, later, that you DO need it.

As ruth says, she found it manageable without drugs. Not eeryone will though, because we do have different pain threshholds.

I was scared into an epi with #2 because they suddenly said, now or never, the anaaesthesiologist is going home...It was getting late at night, and suddenly, I panicked, because I thought, OMG, the md is going home, and not coming back, and what will I do in an hour or two? Will I be able to manage?

I chickened out that I could manage an unmedicated birth, even though I had been doing so great, and was, if I remember correctly dilated to something like 8 cm, because suddenly, I faced something new: the prospect of NOT having an epidural available to me, when I always thought I could eventually get it when and if I needed it.

Suddenly, the prospect of NOT havinng an epi available became very frightening. I was going to lose that choice! And I was scared by NOT having the OPTION of an epidural.

But once I got it, my contractions slowed a lot..and whereas we all thought in an hour or two tops, he would be out, it took several more hours for baby to be born. It really did slow down my labour, and therfore, just prolong the amount of time I did spend in pain. And then I did regret that I had just not "stuck it out" without the epidural.

So, just make an INFORMED DECISION, regardless of what it is.

Happy birthing to everyone!

Franny I know you believe that the above article is fact and an excellent criticism of the meta-analysis. However, the study and evaluation that Dr. Klein conducted is in itself flawed (it does not follow the proper scientific method). This makes this article opinion at best not fact.

Perhaps if you do not believe my take on this, you will consider the opinion of the journal that published the article. YOu see, medical journals have different sections. The research section is where the journal publishes well designed research that has been conducted in a fashion that is consistent with sound scientific principles. When research is conducted in this fashion, then the results can be considered valid (fact). Sometimes an article submited does not meet this criteria and the results can not be considered fact. However, the publishers feel that the author has an opinion worth hearing. In this situation they publish it as an opinion. This is a way that more interest in a particular subject can be generated and hopefully inspire others to do further research on it. When the journal wishes to do this, they place the article in the editorial or opinion section. Look at it. The article is in the editorial section. The journal is not supporting his findings as fact but as an opinion. All this article says is maybe we need to take another look at this. Do not mistake opinion as fact.

So lets look at what the rest of the research is saying. Again the overwhelming majority of the well designed clinical control trials in regards to c-section rates and epidurals show that there is no difference in those with and without epidurals. Although I know the literature on this topic inside and out, yesterday I double checked 2 different medical literature search engines on this topic. I had to scroll through at least 10 articles finding that there is no difference in c-section rates between epidural group and nonepidural group, before I found some old articles or editorials saying otherwise. I think the scientific evidence is pretty clear on c-section rates and epidurals. That is not based solely on the meta analysis mentioned in the editorial mentioned by Franny. It is based on the body of evidence available in journal articles and presented at obstetrical anesthesia conferences.

Being able to critically evaluate scientific medical publications particuarly when they sometimes seem to say different things really does require both a scientific and a medical background. Without this knowledge and experience, you may inadvertantly arrive at the wrong conclusion. Again, I think that it is great to do your own research but be very careful before assuming something is absolute truth. Otherwise, you may end up basing your medical decisions on false assumptions. I recommend clarifying everything you find in your research or read on the internet with a qualified individual. That is an individual with the scientific background, the medical knowledge and specialty experience (if an ob ?, ask an ob, if anesthesia ?, ask an anesthesiologist) necessary to accurately interpert this data and be able to explain how this information applies to your particular case. I think these are important decisions and that you should make it on objective and accurate information.

I agree that you should not be pressured to have medication (or not have medication) during your delivery.

But you should extend that to your OB/Doc as well. Do the research and come up with a plan and make people stick to it!!

I've done my research which shows me that epidurals lead to a higher rate of intervention (episiotomy, c-section, etc.) and can cause the mother to have a more prolonged, difficult labor. These labors and procedures can also cause a more stressful environment for the baby.

Personally, I do not want any medication that leaves me unable to walk or feel the need to pee!!

I will be going med-free when I deliver.

Fortunately, Kara, I do have a science background, and a combined total of 12 years, post-secondary education, as well as 9 years, experience working as a medical secretary in a busy clinic.

I know that you are an md, but do you have a PHD or some other science degree as well? Because you mention that you need the science background as well...

so I was wondering. An md is not a scientist, just as a scientist is not an md.

In my view, if the journal publishes such a study as an editorial, then it is the pinion of the editorial board of that entire journal...they concur. Otherwise, they would publish it seperately under "opinion".(I started out as a journalism major)

I would really appreciate having the names of the articles and their authors to which Kara refers, that were published posterior to the Canadian critique of the meta-analysis....

When you call a roofer to check your roof, he seems to always find and "fix" the problem. When you take your car to a garagist, invariably, they find work to do on your vehicle too.

As a matter of fact, check out this study on ob-gyns in Canada. If that is not an eye-opener, then I do not know what is:

http://www.timescolonist.com/healt...

Dear Hopeful, congratulations..I think you are really brave and inspirational! I think you say it very well...what my concerns are! And it IS a personal choice! I do not think you are less of a mom if you do have an epidural, induction, or c-s...

I wish I was as strong as some of the women in this discussion,
but unfortunately I'm not and I'm really scared of the pain I'm going to go through to have my baby.

You guys are right, it is your own personal choice to have any kind
of medicine during your labor and thankfully my doctor isnt trying
to push me into getting an epidural, when I asked him about it he
kept saying "You don't HAVE to get one, but it'll help". It would just be better for me to get one because I know I'm going to be freaking
out anyway, and I'm afraid to take regular pain medicine such
as statol or dermerol because i don't want to feel loopy.

If it comes to me having to have a c-section though at the end,
I'm sure at that point i won't care and I'll just be ready for it
to be over with so i can hold my baby (=

This is really out of hand ladies. I really think there is absolutely no reason for responses on this site to be antagonistic and nasty. It is about women coming together to share their opinions and ideas in a supportive and kind environment.

In regards to my background. I have shared a lot of personal information on DS (I have been a member of the infertility group and have suffered a miscarriage) and I really do wish to remain anonymous because of that, so I am not going to post my resume. (This is also why I have assumed a pseudonym as my login.) In general I have a Bachelors in science in biology (graduated summa cum laude) 2 years research experience preformed at two of the most prestigious centers in the country with publications in credible journals, medical school (graduated top 5% of my class), Board scores in the top 2% of the nation and trained at one of the highest rated anesthesia residencies in the nation. I don't really feel like I should have to defend myself to you. But, I do have the credentials to know what I am talking about.

As far as the whole epidural debate, I think it is ridiculous that on this site it is getting turned into a debate at all. This is not a debate it is a personal decision. It should be respected like one. This is why I am not just firing back out at you lists of publications. Instead I am refering women to discuss their case with their anesthesiologist. I do feel that when a biased arguement is presented that it is fair to tell them that they are not hearing the whole story.

I realize that in the courtroom things are settled much like a debate. Each person has a side and they present only information in agreement with their arguement. It is the other sides responsibility to defend their side of the arguement.

Healthcare issues should not be decided in this fashion. Women have a right to be presented with unbiased information and decide what is right for them. Also, the information should be conveyed as it pertains to them based on their medical history.

I am not going to be bullied or antagonized. I have tried to reach reconciliation in a private and respectful fashion with you but clearly that has not worked. You prefer to publicly attack my credentials. This is not a healthy discussion. It is not in the spirit of DS.

As for closing remarks regarding this topic.

The number 1 contraindication to placing an epidural according to my anesthesia textbooks is THE PATIENT DOES NOT WANT IT. This is your body and you have to decide what is right for you. As I have said before you should not be pushed into or scared out of one. You should be presented with the risks and the benefits based on your particular case. I say your particular case because in some medical conditions the risks are increased in other medical conditions there are major physiologic advantages to the epidural making it safer to have one.

Those of you who are not interested in epidurals. I completely respect your decision and in no way am I trying to talk you into one.

To those of you trying to decide about what is right for you.

Many of the posts placed here have presented only part of the picture. For example, in regards to wether epidurals slow down labor. The research on this subject is conflicting. In the results from 2 separate meta analysis studies conducted in early 2000s, showed that 1st stage of labor (cervical dilation) was slowed by approximately 45 and 26 minutes minutes, and second stage (pushing) slowed by 15 minutes (Warning one of these is the same study Franny 7 does not think was valid based on the article criticizing it in CFP. Of course that did not stop her from quoting it when it agreed with her position about slowing labor. According to good scientific practice if a study is bad, all of its results have to be thrown out. So you decide what you think. I dont think the study was bad so I am continuing to present it. Like I said it is not about sides it is about giving you unbiased information and letting you decide). These studies included data gathered from 1980-2000. As I have mentioned before epidural analgesia has progressed through the years medications and dosages have changed and with that we have seen a change in effects. Some newer studies have shown no significant change in 1st stage of labor but a continued increase in 2nd stage of 15 minutes. Others have shown no difference in either stage. There have been several studies that have shown that with a low dose epidural labor is faster (ranging from 30 to 90 minutes) than the non-epidural group. The theory behind why this may be happening is that pain causes the release catecholamines. Catecholamines inhibit labor. Therefore, if you can find a type of local and dose that does not inhibit labor but prevents pain from its inhibitory effects, you may be able to hasten labor. Additionally newer studies are challenging the results of earlier studies in regards to timing of epidural placement and effect on labor progression. They are showing contrary to previous studies that it does not matter when you get an epidural early or late. There is no difference in labor or c-section rates.

Discuss these studies with your anesthesiologist. They will be able to tell you how they pertain to your case. Also, many of the most credible medical journals are accessible only if you have a subscription or belong to a medical library with a subscription. Therefore, your doctor will have access to information that is not available on the general internet. They also attend medical conferences where the most up to date research is presented prior to publication. Plus their knowledge and experience all of these things make them a valuable resource.

This is one example of something where the evidence is not as one sided as some of the posts have presented. So I again encourage you to research on your own read others posts and ask your doctor about those to.

In regards to how things are posted on DS and how it can be misleading. I could very easily post Epidurals speed up labor. Then I could cite several articles from credible journals and claim it as fact. This would clearly be wrong because it would fail to show you the whole picture. It would tend to paint a rosy picture of epidurals that would talk you into one. But it would ignore other evidence that is also a possibility.

Do I think it is equally wrong to say epidurals slow down labor and not present the other studies? Absolutely. For the same reason. It tells only part of the story and tends to try to scare you out of one.

This is why healthcare decisions should not be settled in debate forum. What if one person is a better debater than the other. Do you only get half the story? Is that really how you want to get information about your medical decisions? I think anyone who considers themselves qualified to teach you about epidurals should be able to give you an unbiased presentation of all the information just not those in support of their side. Then give you the respect and autonomy to decide for yourself.

In regards to the c-section rate and epidurals, like I said the truth is that the overwhelming majority of medical literature says it does not make a difference. The well conducted clinical control trials are coming up with same conclusions.

Do your own research, read others opinions on the internet, and talk to your doctor and decide what is right for you.

As I mentioned I have been a member of other groups on DS where controversial medical treatments have been discussed and I have never seen people disrespected the way they have been on this site. I am not just pointing a finger at Franny. People on both sides have said things that were not supportive of each other.

The difference on the other sites has been that people respected each other. Birth is a normal and beautiful process. As Franny has said about other issues even in natural processes things don't always happen easy and complications occur. Regardless of the birth plan you decide on there are risks and benefits. There are R and B to giving birth in a birthing center, in a hospital, getting an epidural etc. We will look at the same list of risks and benefits and some will decide one thing others will decide another. What is important is that we choose what is right for us. Scaring people with one sided presentations is no way to treat each other.

I think that if you are not an expert on something, you should not talk like you are. Recognize that your opinion may only represent part of the puzzle and if you present only one piece of the puzzle, that the recipient may not be able to see the whole picture. In this way you may hinder their ability to make a truly informed decison.

Good night and good luck to all. I am officially finished with this post. So my failure to reply does not mean I agree with what is being said. It means that I will no longer be a part of this ridiculous behavior.