This is the beginning of a three-part series of posts from family practice physician, pediatrician , neonatologist and Senior Scientist for the Centre for Developmental Neuroscience and Child Health and the Family Research Institute, Dr. Michael Klein, who will share this thoughts and analysis with us regarding epidural analgesia...

A short history of epidural analgesia
It was not until the 1960s and 1970s that epidural analgesia became widely available. Prior to that, anaesthesia services dedicated to the provision of epidural analgesia did not exist. By the 1990s, obstetrical anaesthesia services dedicated to maternity care became common in developed countries.

Prior to the ready availability of epidural analgesia in labour and delivery departments, maternity nurses used their skills to reassure, massage, breathe with the woman through contractions, and employ a range of other methods to handle labour pain. But today, the shortage of staff and the institutional demands on nurses make these skills relatively unavailable. In addition, the education of nurses has taken a more technical turn; the 'old-fashioned' skills of hands-on nursing has been replaced, in many educational programs, by teaching technical skills related equipment and medical interventions.

It became clear that to make epidural analgesia reliably available, a dedicated anaesthetic staff had to develop. Once such staffs were in place, there was great pressure to keep them busy. After epidurals became more available, a debate ensued, and goes on to this day, about whether withholding an epidural was interfering with a woman's autonomy. This discussion did not seem to take into consideration that women might not select an epidural if they knew more precisely how long severe pain would last, or if they understood the benefits and problems associated with epidural use, or if staff were trained in a variety of other effective techniques to assist with the pain of labour. In fact, many women are directly or indirectly pressured into accepting epidurals.

The implications of epidural use
Although it first seemed that epidural analgesia freed up nurses to care for more than one woman at a time, in fact, it soon became clear that the labour and delivery nurse's time was consumed by the technical requirements of safely managing the epidural and the rest of the technical requirements of her job, leaving little time for hands-on nursing support.(1) A woman who has an epidural requires an intravenous line and continuous electronic fetal monitoring to measure both the fetal heartbeat and the uterine contraction pattern. Because labour usually slows after an epidural, the woman typically requires synthetic oxytocin (Pitocin) augmentation to replace her natural oxytocin production, which is inhibited by the epidural itself. Pitocin can cause painful and very strong contractions: therefore its use requires detailed charting and monitoring for the potential complications of the epidural.

Usually after the introduction of an epidural, a woman has to remain in bed because she cannot feel her legs and she is attached to many wires and lines, so this limits her ability to walk or change position. 'Walking epidurals' and telemetry are available only in rare settings and by particular anaesthesiologists. Tethered to intravenous lines and other lines (e.g. urinary catheter, blood pressure cuff, fetal monitor and the tocometer) and unable to walk, it is almost impossible for the woman to use gravity and different positions to help progress her labour.

The development of new pain management techniques
Prior to the availability of epidural analgesia, the childbirth education movement utilized a variety of techniques that were physiologically and psychologically helpful to reduce pain, such as breathing and imagery. These methods began to take hold in the culture in the 1950s and 1960s but today are less prominent in many childbirth education classes. Some classes are more focused on teaching women compliance with particular hospital technological methods and approaches, routines and policies, rather than on teaching women coping skills.

In the late 1970s and early 1980s, the first studies appeared, showing the value of continuous emotional and physical support by a caring, trained and knowledgeable woman, whose responsibility was to focus solely on the labouring woman rather than on the institution or equipment - the doula. Backed by randomized studies,(2-4) it has become apparent that this emotional and physical continuous support from a doula gives a woman more confidence and ability to work with her labour. All studies to date have demonstrated that hospital-based nurses cannot function as doulas,(5, 6) even if those nurses are midwifery-trained. It is not the fact of being either a midwife or a nurse that matters, but the fact that when these care providers areemployed by the hospital, their primary allegiance is to the institution, and they areprofessionally responsible for the conduct of the labour and the safety of both mother and fetus. A doula who is employed by the woman is responsible only to her. Autonomous midwives in the Canadian context are strongly supportive of doulas, with whom they frequently work in collaboration.

Pain moderation by transcutaneous nerve stimulation (TNS) or intradermal water injections can be very helpful, especially in the earlier stages of labour. Other non-pharmacological methods like water baths or showers or movement, including the use of birth balls, are also helpful for many women who find that partial pain relief is sufficient to help them through contractions. Doula care provides a complementary approach which can reduce the need for an epidural or delay epidural usage until the active phase of labour, when some of the negative effects of epidural analgesia are reduced. In particular, during her labour, doula care and non-pharmacological approaches allow the mother more opportunity to produce her own oxytocin. Natural oxytocin has some important effects: it is the anti-stress hormone, and helps contractions to be more productive; it is also the 'love hormone' that later goes on to enhance the bonding process following the baby's birth - an effect suppressed by synthetic oxytocin, little of which enters the brain of either mother or fetus.

Is epidural analgesia the best form of pain relief?
Epidural analgesiais a very effective form of pain relief, meaning that compared to a variety of other pharmacological and non-pharmacological methods, it provides generally consistent pain reduction. If there were no problems associated with epidural analgesia, almost everybody would want it. Unfortunately, though, associated with its use there are various undesieable effects, including:

• longer first stage labours
• longer second stage labours
• increased incidence of maternal fever directly caused by the epidural, which often leads to the use of antibiotics in both the labouring woman and her newborn
• increased rates of operative vaginal delivery (forceps and vacuum)
• increased perineal trauma with and without instrumental births - including severe tears into the rectum (3rd and 4th degree tears).
• a variety of complications such as a placement of an epidural too high on the spine (leading to breathing problems).
• failure of the epidural to provide any pain relief, or insufficient pain relief-requiring the continued use of other methods of pain relief
• increased need for a bladder catheter
• maternal hypotension leading to worrying fetal heart rate changes
• an increase in the likelihood of the need for a cesarean section - this last complication being the subject of great debate, which will be discussed further

Of course, some of these problems may occur whether the epidural was or was not truly needed. And when an epidural is truly needed for pain relief or to solve a specific problem, it can dramatically change a situation for the better and can improve outcome. It is only when epidurals are used routinely, and especially very early in labour that these complications are more likely to occur.

Dr. Klein's next post will take a look at the research on epidurals and discuss the risks and benefits of this pain relief technology.
All references for this post series can be found here: References _ michael klein post.

Posted By: Michael C. Klein, MD, CCFP, FAAP(Neonatal-Perinatal),FCFP, ABFP
Emeritus Professor of Family Practice and Pediatrics University of British Columbia
Senior Scientist Emeritus
Centre Developmental Neuroscience and Child Health
Child and Family Research Institute
4500 Oak Street
Vancouver, V6H 3N1
Tel: 604-875-2000 ext 5078
Fax: 604-875-3569
Email: mklein@interchange.ubc.ca

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