Management of Labor Pain: Promoting Patient Choice
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In 2001, the Nature and Management of Labor Pain symposium (see Leeman, et al.,1 in this issue) brought together family physicians, obstetrician–gynecologists, nurse-midwives, childbirth educators, and anesthesiologists for a critical analysis and discussion of systematic reviews on labor pain.1 The symposium occurred in the context of the increasing use of epidural analgesia, which is now used in almost two thirds of labors in the United States.2 Presentations showed that epidural analgesia is a more effective pain-relief method than intravenous narcotics,3,4 the second most common pharmacologic method of pain relief (used in 30 percent of labors).2,5 In the First National U.S. Survey of Women's Childbearing Experiences,2 78 percent of women rated epidural analgesia as very helpful.
Most women in the United States deliver infants in hospitals where epidural analgesia or intravenous narcotics are the only pain-relief options. Alternative pharmacologic methods for pain relief, including nitrous oxide and paracervical blocks, are used infrequently in the United States. Despite numerous studies showing that use of doulas and continuous labor support results in a decreased need for medical intervention, improved maternal and newborn outcomes, and increased maternal satisfaction, few women are afforded this option.6
Although epidural analgesia clearly is a highly effective and popular method of providing labor analgesia, it has significant potential side effects. Symposium presentations showed that epidural analgesia may increase the length of labor, the need for operative vaginal delivery, and the likelihood of perineal laceration.4,7 Epidural analgesia can cause maternal fever, with consequent increased use of neonatal antibiotics and sepsis evaluations.4,7 Whether epidural analgesia results in a higher rate of cesarean delivery or is a confounder based on its use in “difficult” labors remains a point of controversy. Physicians who frequently use epidural analgesia may have a maternity practice style that leads to higher cesarean rates as a result of earlier hospital admission, increased use of oxytocin augmentation, and decreased presence of the physician.8
The childbirth survey showed that many women are poorly informed about the potential side effects of epidural analgesia.2 To make an informed choice, women should be told of the risks and benefits during prenatal care rather than in the midst of labor. Symposium participants acknowledged the scarcity of data about the effects of epidural analgesia on newborn behavior, breastfeeding, and maternal-infant bonding, and they highlighted the need for future research in these areas.
A technologic birthing model that uses labor induction, epidural analgesia, continuous electronic fetal monitoring, and cesarean delivery increasingly dominates labor and delivery wards in the United States and other industrialized countries. Conference participants expressed concern that when institutional epidural rates are high, other methods of labor support, such as childbirth classes, doulas, nurses trained in supporting nonmedicated childbirth, and availability of other pain control modalities, may not be offered. In many hospitals, labor pain management options are limited to epidurals, parenteral analgesics, or rudimentary labor support from overextended nurses. An anesthesiologist at the symposium remarked that “While there may be problems with high epidural usage, in the presence of our nursing shortages and economic or business considerations, having a woman in bed, attached to an intravenous line and continuous electronic fetal monitor and in receipt of an epidural may be the only realistic way to go.”
Access to professional labor support is considered a luxury for patients in most U.S. hospitals, and lack of access to epidural analgesia may result in legal action.9 The issue of patient choice is being used as a pretext for increasing technologic intervention in the birth process. A past president of the American College of Obstetricians and Gynecologists called for the right of a patient to choose cesarean delivery in the absence of maternal or fetal indications,10 and the American Society of Anesthesiologists suggests closing smaller hospitals that are unable to support universal access to epidural analgesia.11 However, neither organization advocates a broader range of labor support and pain management options to promote patient choice. Brazilian women are “choosing” cesarean delivery partly out of concern that they won't receive adequate medical care during labor.12,13 Similarly, in many hospitals, American women may feel that epidural analgesia is the only real choice they have.
Family physicians providing maternity care may feel “out of the loop” as a result of the predominant use of epidural analgesia for labor pain. The request for epidural analgesia may be conveyed to the anesthesiologist by the nursing staff, with only a perfunctory nod from the primary caregiver. In contrast to this inappropriate trend, the request should be viewed as a consultation.14 As with any consultation, the family physician has the responsibility to be a knowledgeable advocate for the patient—taking the time to learn which epidural drugs and techniques are used in a specific hospital and understanding their effectiveness, potential side effects, and limitations.
Family physicians can seek ways to learn alternative approaches to epidural analgesia and incorporate them into practice. They, along with other maternity care providers, should be knowledgeable about and supportive of a range of pain management options in their hospitals, birthing centers, and communities. The Family-Centered Maternity Care course sponsored by the American Academy of Family Physicians (www.aafp.org/x14376.xml) offers sessions on labor support, labor positions, and sterile water injections for women with “back labor.” Family physicians should support prenatal childbirth preparation and education; these steps are essential to set appropriate expectations for an event that can be a sentinel experience for many women and their families.
Labor and delivery units should not operate on the expectation that every woman will use epidural analgesia during labor. Other choices, such as labor support and doulas, nonpharmacologic pain-relief methods, and pharmacologic pain-relief methods other than intravenous narcotics or epidurals, should be available. We await research into which pain-relief options women would choose if they had a greater range of choices, how these methods can be used most effectively, and how all methods affect the birthing woman, her labor, and her infant.15
Lawrence Leeman, M.D., M.P.H., is assistant professor of family and community medicine and obstetrics and gynecology at the University of New Mexico School of Medicine, Albuquerque.
Patricia Fontaine, M.D., M.S., is associate professor of family practice and community health at the University of Minnesota School of Medicine, Minneapolis.
Valerie King, M.D., M.P.H., is assistant professor of family medicine at the University of North Carolina School of Medicine, Chapel Hill.
Michael C. Klein, M.D., is professor of family practice and pediatrics at the University of British Columbia Faculty of Medicine, Vancouver, and McGill University Faculty of Medicine, Montreal.
Stephen Ratcliffe, M.D., M.S.P.H., is adjunct professor of family practice at the University of Utah School of Medicine, Salt Lake City, and program director of the Lancaster (Pa.) Family Practice Residency.
Address correspondence to Lawrence Leeman, M.D., M.P.H., University of New Mexico School of Medicine, Department of Family Practice, 2400 Tucker NE, Third Floor, Albuquerque, NM 87131 (e-mail: email@example.com). Reprints are not available from the authors.
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