Doulas: love them or hate them.

Specialties Ob/Gyn

Published

I am trying to get a better understanding on why my co-workers hate doulas and I am pretty sure it comes down to control. There are 2 local hospitals with L&D and one welcomes doulas and mine hates doulas. The other hospital knows some doulas by name and greets them warmly. If a patient is sent for a section, the doula almost always accompanies the mother (along with the FOB or main support person) to the OR.

It's very different where I work. I hired a doula and sensed the hostility towards them at my hospital. My co-workers didn't know prior that I was going to have one there. I knew I had a strong possibility of a section and I wanted emotional support to avoid medication in hopes to avoid a c-section. I did end up with a section... because I work there my doula came to the OR with me. But, NEVER have I seen another doula go back there. My doula does not want to take patient delivering at my hospital anymore. She has been treated so poorly. I am now friends with a few doulas in the area and they all say the same thing about my hospital.

I took care of a woman with a doula a few months ago. I did not know this doula at all. I smiled at her, addressed her by name and when ambulating the mother, I accepted her assistance when she offered it. At one point I offered to get the mother and doula a water. She followed me out of the room and told me that no one at this hospital has even been this nice to her. I'm not surprised to hear her say this. The sad part is that I didn't give her special treatment, I just acknowledged her as a human being.

When I ask my fellow co-workers, they have said, "I just don't see the point of a doula/Why not just have your mother there?" (This is when I mention that studies have shown that doula support can increase your chances of an unmediated birth as well decrease your chances of c-section. I can give many more reasons for a doula vs. mother/sister/friend.) And they have told me that doulas give their patients medical advice and they don't like that. Or that doulas are pushy and always suggesting position changes or decreased monitoring.

One of my doula friend knows a charge nurse. We have all suggested having a "meet the doulas" day. This way the nurses can ask questions or even create boundaries on what is considered medical advise and maybe we can all work together without tension in the future. This ended up fizzling out. I know the only nurses who would come are the very few that like doulas. One of the other nurses confided in me that she was a doula prior to becoming an OB nurse, but she didn't want anyone else to know.

Thank you if you took the time to read all of this. I would love to hear some of your perspectives.

Specializes in OB, Family Practice, Pediatrics.
Really, I would like to see the research that shows that doulas improve health of moms and babies. Your making a big jump assuming that decreased intervention rates=better outcomes.

You will have to show me where HIPPA makes determinations on who is a healthcare provider and who isn't.

Any time a mom and baby are not exposed to unnecessary medications and major surgery they have better outcomes and more successful breastfeeding, bonding and less postpartum depression. There are many research studies that show that many of the interventions used in pregnant low-risk women are not evidence based; and subject moms and babies to unnecessary risks. I don't have the time to look up the studies for you, but they are out there if you want to look.

http://www.hipaa.com/2009/05/the-definition-of-health-care-provider/

The NPI for Doulas is under the category of Nursing Service Related Provider Types

Definition: Providers who are trained and educated to perform and administer services

related to health promotion, disease prevention, acute and chronic care, spiritual guidance

and comfort for healing and health, and health maintenance across the lifespan.

Source: American Nurses Association, American Nurses Credentialing Center, 1996

Certification Catalog P.5 and NUCC

When I posted, it was not my intention to start a battle. As I stated earlier, I work very well with the birth team and show respect to the staff involved in each birth. It seems that maybe you have had bad experiences with Doulas, and that is unfortunate. I noticed that you are not an L&D nurse, but a nurse anesthetist, which may be why you hold a different view of Doulas.

Specializes in Anesthesia.
Any time a mom and baby are not exposed to unnecessary medications and major surgery they have better outcomes and more successful breastfeeding, bonding and less postpartum depression. There are many research studies that show that many of the interventions used in pregnant low-risk women are not evidence based; and subject moms and babies to unnecessary risks. I don't have the time to look up the studies for you, but they are out there if you want to look.

http://www.hipaa.com/2009/05/the-definition-of-health-care-provider/

The NPI for Doulas is under the category of Nursing Service Related Provider Types

Definition: Providers who are trained and educated to perform and administer services

related to health promotion, disease prevention, acute and chronic care, spiritual guidance

and comfort for healing and health, and health maintenance across the lifespan.

Source: American Nurses Association, American Nurses Credentialing Center, 1996

Certification Catalog P.5 and NUCC

When I posted, it was not my intention to start a battle. As I stated earlier, I work very well with the birth team and show respect to the staff involved in each birth. It seems that maybe you have had bad experiences with Doulas, and that is unfortunate. I noticed that you are not an L&D nurse, but a nurse anesthetist, which may be why you hold a different view of Doulas.

So, as a Doula you know which interventions are necessary and you assume that all medical interventions are basically unnecessary. The fact that epidurals can help regulate BP(decrease eclampsia in pre-e),provide more positive birthing experiences for mothers d/t decreased pain, decrease mortality rates for c-sections is just a totally lost I guess. I am aware of the research, but your training is all one-sided. Doula training paints the low risk, low/no intervention as the best way to go for labor. As an APN,just like Obstetricians we have to learn both sides of spectrum of the risks and benefits to the mother and baby. The good and the bad. Medical interventions are what have made delivery very safe. It isn't Doulas making labor safe for patients. Doulas should be there for the comfort of the mother nothing more.

Patients can have depression for a variety of reasons, and pain is one of them.

I don't mind doulas. There is just a line I don't think that should be crossed by a minimally trained unlicensed personnel, and that is giving medical advice.

Just because a Doula can get an npi number doesn't make them a healthcare provider.

Federal definition of a healthcare provider. http://hr.commerce.gov/Employees/Leave/DEV01_005930

Doulas may squeak by under federal definitions, but that doesn't mean as an anesthesia provider I/we recognize doulas as healthcare providers. I certainly don't listen to a doulas input or solicit their input when discussing labor analgesia with laboring moms.

All in all I have neither good or bad interactions with Doulas, but I have also never had one try to interfere or explain any anesthesia/medical interventions to the patient while I was around.

Specializes in Labor and Delivery, Medical, Oncology.

To be fair, I don't think doulas would identify themselves as "healthcare providers" even if they are categorized as such. As I mentioned before, doulas don't provide medical interventions; their role is strictly supportive with that support outlined by the client. Those who have other credentialing they intend to use in the role of "doula" (eg: nurse, midwife, massage therapist, yoga instructor, aromatherapist, ect) are asked by DONA to not identify themselves as doulas in order to avoid confusion as to what a doula does.

Specializes in OB, Family Practice, Pediatrics.
So, as a Doula you know which interventions are necessary and you assume that all medical interventions are basically unnecessary. The fact that epidurals can help regulate BP(decrease eclampsia in pre-e),provide more positive birthing experiences for mothers d/t decreased pain, decrease mortality rates for c-sections is just a totally lost I guess. I am aware of the research, but your training is all one-sided. Doula training paints the low risk, low/no intervention as the best way to go for labor. As an APN,just like Obstetricians we have to learn both sides of spectrum of the risks and benefits to the mother and baby. The good and the bad. Medical interventions are what have made delivery very safe. It isn't Doulas making labor safe for patients. Doulas should be there for the comfort of the mother nothing more.

Patients can have depression for a variety of reasons, and pain is one of them.

I don't mind doulas. There is just a line I don't think that should be crossed by a minimally trained unlicensed personnel, and that is giving medical advice.

Just because a Doula can get an npi number doesn't make them a healthcare provider.

Federal definition of a healthcare provider. http://hr.commerce.gov/Employees/Leave/DEV01_005930

Doulas may squeak by under federal definitions, but that doesn't mean as an anesthesia provider I/we recognize doulas as healthcare providers. I certainly don't listen to a doulas input or solicit their input when discussing labor analgesia with laboring moms.

All in all I have neither good or bad interactions with Doulas, but I have also never had one try to interfere or explain any anesthesia/medical interventions to the patient while I was around.

I have tried to be respectful in this dialogue; however, I resent your continued implications that Doulas don't have working brains. If you read my last post, the NPI description for Doulas, being under Nursing Service Related Providers is based on the American Nurse Association, ANCC definition of what they define Nursing Service Related Providers to be and the Federal government has used this in how they have arrived at their definition for Doulas.

I am also fully aware of the effects of epidurals. If you read what I wrote, I said the use of many interventions are not evidence-based in low-risk pregnant women. Pre-eclampsia is not "low-risk" and the use of epidurals for C-Sections reducing mortality is misleading; yes they have reduced mortality over "general anethesia"; but the fact remains that the epidural/pitocin combination frequently is the cause of MORE C-sections with increased pain and recovery time and more depression.

As I said, I don't have a problem with "necessary" interventions; but many interventions that are done are not "medically necessary" and cause more problems.

One more time, in regard to the training of Doulas...Yes, some Doulas may be minimally trained if they only attend the required weekend workshop; afterwards they can call themselves a Doula. But, you are assuming that they have had no other training; many nurses have become Doulas. In addition to that, some of those that you think are Doulas are Certified Monitrices and Certified Midwife Assistants, many of whom are also nurses. In order to become a Certified Doula, which are the ones that can be reimbursed by insurance, the training process can take years. You also have no idea of what their background and training is, many of them are also nurses. Contrary to your belief, Certified Doulas are also trained in the "spectrum of risks/benefits to moms and babies". Licensing is reserved for those professions that have been shown to have the potential to cause harm to patients/clients/customers. It has nothing to do with the training, skills and abilities of a professional. Certification is reserved for professionals that have been trained beyond the miniminally required skills to practice; ex: Certified Nurse Midwife, Certified Professional Midwife, Certified Substance Abuse Counselor, Certified Public Accountant, Certified Birth Doula, Certified Labor Doula.

It is obvious that you don't like Doulas because they do affect the rates of epidurals, which affects your bottom line.

I'm done, I have patients to see.

Specializes in Anesthesia.
I have tried to be respectful in this dialogue; however, I resent your continued implications that Doulas don't have working brains. If you read my last post, the NPI description for Doulas, being under Nursing Service Related Providers is based on the American Nurse Association, ANCC definition of what they define Nursing Service Related Providers to be and the Federal government has used this in how they have arrived at their definition for Doulas.

I am also fully aware of the effects of epidurals. If you read what I wrote, I said the use of many interventions are not evidence-based in low-risk pregnant women. Pre-eclampsia is not "low-risk" and the use of epidurals for C-Sections reducing mortality is misleading; yes they have reduced mortality over "general anethesia"; but the fact remains that the epidural/pitocin combination frequently is the cause of MORE C-sections with increased pain and recovery time and more depression.

As I said, I don't have a problem with "necessary" interventions; but many interventions that are done are not "medically necessary" and cause more problems.

One more time, in regard to the training of Doulas...Yes, some Doulas may be minimally trained if they only attend the required weekend workshop; afterwards they can call themselves a Doula. But, you are assuming that they have had no other training; many nurses have become Doulas. In addition to that, some of those that you think are Doulas are Certified Monitrices and Certified Midwife Assistants, many of whom are also nurses. In order to become a Certified Doula, which are the ones that can be reimbursed by insurance, the training process can take years. You also have no idea of what their background and training is, many of them are also nurses. Contrary to your belief, Certified Doulas are also trained in the "spectrum of risks/benefits to moms and babies". Licensing is reserved for those professions that have been shown to have the potential to cause harm to patients/clients/customers. It has nothing to do with the training, skills and abilities of a professional. Certification is reserved for professionals that have been trained beyond the miniminally required skills to practice; ex: Certified Nurse Midwife, Certified Professional Midwife, Certified Substance Abuse Counselor, Certified Public Accountant, Certified Birth Doula, Certified Labor Doula.

It is obvious that you don't like Doulas because they do affect the rates of epidurals, which affects your bottom line.

I'm done, I have patients to see.

We will have to agree to disagree. A nurse that is also a Doula is totally different than a Doula whose only training is weekend course and observing a few deliveries.

"My bottom line"....:lol2: Now that is funny. You should really look at my posted background information before you post stuff about me. I am a military/USAF CRNA. The way the current bonus structure is in the USAF and because I am in my payback years for school I make less than I would have staying in the ICU. I have med-surg nurses making more than I do at my hospital. So yes, I am really in for it the money.

Specializes in L&D/Maternity nursing.
Really, I would like to see the research that shows that doulas improve health of moms and babies. Your making a big jump assuming that decreased intervention rates=better outcomes.

Not so much a big jump actually. There is plenty of research stating such. Just as there is plenty of research stating that anesthesia (i.e. epidurals) leads to a cascade of sometimes unnecessary interventions, such a pitocin augmentation, AROM, and forceps/vac-extract/episiotomy deliveries. Its hard to link such articles here as one needs a subscription, but they all exist. One just needs to look in the right place is all.

Specializes in Anesthesia.
Not so much a big jump actually. There is plenty of research stating such. Just as there is plenty of research stating that anesthesia (i.e. epidurals) leads to a cascade of sometimes unnecessary interventions, such a pitocin augmentation, AROM, and forceps/vac-extract/episiotomy deliveries. Its hard to link such articles here as one needs a subscription, but they all exist. One just needs to look in the right place is all.

Post em and we can discuss them(post the titles and authors). Don't post them and there is nothing to discuss.

Specializes in Anesthesia.

I know my research, and if you believe that epidurals increase instrument deliveries or c-sections you are mistaken.

J Obstet Gynecol Neonatal Nurs. 2008 Jan-Feb;37(1):4-12.

A meta-analysis of passive descent versus immediate pushing in nulliparous women with epidural analgesia in the second stage of labor.

Brancato RM, Church S, Stone PW.

Source

Columbia University, New York, NY, USA. [email protected]

Abstract

OBJECTIVE:

To determine which method of pushing-passive descent or early pushing-most benefits women with epidurals during second-stage labor.

DATA SOURCES:

MEDLINE, CINAHL, and Cochrane Database.

STUDY SELECTION:

Studies limited to randomized controlled trials in English, comparing passive descent to early pushing in women with effective epidural analgesia.

DATA EXTRACTION:

A hand search was performed. Data included number of instrument-assisted deliveries (forceps and vacuum); noninstrumental or spontaneous lady partsl births, cesarean births, pushing time, episiotomies, lacerations; maternal fatigue; and fetal well-being.

DATA SYNTHESIS:

Seven studies were eligible for a sample size of 2,827 women. Pooled data indicate that passive descent increases a woman's chance of having a spontaneous lady partsl birth (relative risk: 1.08; 95% confidence interval: 1.01-1.15; p = 0.025), decreases risk of having an instrument-assisted deliveries (relative risk: 0.77; 95% confidence interval: 0.77-0.85; p

CONCLUSIONS:

Significant positive effects were found indicating that passive descent should be used during birth to safely and effectively increase spontaneous lady partsl births, decrease instrument-assisted deliveries, and shorten pushing time.

J Perinat Educ. 2003 Spring;12(2):16-21.

Exploring Women's Preferences for Labor Epidural Analgesia.

Stark MA.

Source

M ary A nn S tark is an assistant professor in the Bronson School of Nursing at Western Michigan University in Kalamazoo, Michigan.

Abstract

The purpose of this study was to explore demographic factors related to women's prenatal preferences for using an epidural during labor. Women recruited from prenatal classes provided data for this descriptive correlational study. Women with the most education, income, and parity indicated greatest preference for epidural analgesia. Thus, these women may be comfortable with the technology and most likely to be willing to pay for epidurals and to select care providers who provide epidural anesthesia. In this sample, prenatal preference for an epidural was not predictive of actual use, although it has been shown to be predictive in previous research.

J Midwifery Womens Health. 2007 Jan-Feb;52(1):31-6.

Does epidural analgesia affect the rate of spontaneous obstetric lacerations in normal births?

Albers LL, Migliaccio L, Bedrick EJ, Teaf D, Peralta P.

Source

University of New Mexico College of Nursing, Nursing/Pharmacy Building, Room 216, Albuquerque, NM 87131-5688, USA. [email protected]

Abstract

The precise relationship between epidural use and genital tract lacerations in normal childbirth is unclear. Data from a clinical trial on measures to lower genital tract trauma in lady partsl birth were used for a secondary analysis. The goal was to assess whether epidurals affect the rate of spontaneous obstetric lacerations in normal lady partsl births. Maternal characteristics and intrapartum variables were compared in women who did and did not use an epidural in labor, and also in those with and without any sutured lacerations following lady partsl birth. Variables that were statistically different in both cases were entered into regression equations for simultaneous adjustment. Epidural use was not an independent predictor of sutured lacerations. Predictors of sutured lacerations included nulliparity, a prolonged second stage, being non-Hispanic white, and an infant birthweight greater than 4000 grams. Elements of midwifery management need further research.

Eur J Obstet Gynecol Reprod Biol. 2006 Sep-Oct;128(1-2):270-5. Epub 2005 Dec 15.

Use of epidural analgesia and its relation to caesarean and instrumental deliveries-a population--based study of 94,217 primiparae.

Eriksson SL, Olausson PO, Olofsson C.

Source

Department of Anaesthesia and Intensive Care, Gävle County Hospital, SE-80187 Gävle, Sweden. [email protected]

Abstract

OBJECTIVES:

To investigate the association between epidural analgesia for labour-pain relief and mode of delivery.

STUDY DESIGN:

The Swedish medical birth register covers 99% of all births and contains prospectively collected information from all delivery units in Sweden. The present population-based cohort study includes singleton births among nulliparae during 1998-2000, excluding deliveries with elective caesarean section, giving study population of n=94,217. The frequencies of epidural block in this population were estimated for each delivery unit. The outcomes studied were non-elective caesarean section and instrumental delivery.

RESULTS:

There was no clear association between frequency of epidural block and caesarean section and instrumental delivery, respectively. Delivery units with the lowest (20-29%) and the highest (60-64%) relative frequencies of epidural block had the lowest proportion of caesarean section (9.1%). For the other groups the proportion varied between 10.3 and 10.6%. Instrumental deliveries were most common, 18.8%, in delivery units with 50-59% frequency of epidural block use. The lowest incidence (14.1%) was in units using epidurals in 30-39% of cases. In the other groups (20-29, 40-49 and 60-64%) the proportion varied between 15.3 and 15.7%.

CONCLUSIONS:

This investigation shows no clear association between epidural use and caesarean section or instrumental delivery, indicating that there is no reason to restrict the epidural rate to improve obstetric outcome.

Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.

The first three studies you posteddid not prove or disprove what you were arguing. Did you read what you posted? The first study examined passive descent vs. Immediate second stage pushing. The second study was only examining Women's PRENATAL opinions of epidural use, and the third examined the relationship between epidurals and spontaneous lacs.

Only the last study really addressed what you were arguing - that epidurals don't increase the incidence of instrumental deliveries or C/S. For that one study you posted that states it does not, I'm sure I can find one that does. Let me go look...

Specializes in L&D/Maternity nursing.

Just a few to ponder...

JOGNN, 35, 456–464; 2006. DOI: 10.1111/J.1552-6909.2006.00067.x

A Randomized Control Trial of Continuous Support in Labor by a Lay Doula

Della A. Campbell, Marian F. Lake, Michele Falk, Jeffery R. Backstrand

Results:  Significantly shorter length of labor in the doula group, greater cervical dilation at the time of epidural anesthesia, and higher Apgar scores at both 1 and 5 minutes. Differences did not reach statistical significance in type of analgesia/anesthesia or cesarean delivery despite a trend toward lower cesarean delivery rates in the doula group.

Conclusion:  Providing low-income pregnant women with the option to choose a female friend who has received lay doula training and will act as doula during labor, along with other family members, shortens the labor process

J Dev Behav Pediatr. 2003;24:195–198

Benefits of a Doula Present at the Birth of a ChildMartian T. Stein, MDhttp://pediatrics.aappublications.org/content/114/Supplement_6/1488.full

some excerpts from the article:

"a result, an RCT of healthy women, each of whom was expecting to be supported by her male partner, was conducted. All could have family members present. A cesarean delivery was required by 22.5% of the women who were accompanied only by a male partner compared with 14.2% of those supported by both the father and a doula. This study showed the value of doula support for all mothers whether laboring alone or with a partner. The doula does not displace the father but supports him, shows him how he can be helpful, and relieves much of his anxiety."

"There were favorable effects of doula support on the subsequent psychological health of the women and infants. At 6 weeks there were impressive postpartum behavioral differences: a significantly greater proportion of doula-group women were breastfeeding (51% compared with 29%), and the doula-group women were significantly less anxious, had lower scores on a test of depression, and had higher levels of self-esteem. These maternal qualities would be favorable for the development of the infants."

Obstetrics & Gynecology, Vol 88(4), October 1996, Pages 739-744

Continuous labor support from labor attendant for primiparous women: A meta-analysis

Jun Zhang MB, PhD, James W. Bernasko MB, ChB, Etel Levbovich, Marianne Fahs PhD, Maureen C. Hatch PhDData Extraction and Synthesis Meta-analysis of four studies conducted among young, low-income, primiparous women who gave birth on a busy labor floor in the absence of a companion suggested that continuous labor support by a labor attendant shortens the duration of labor by 2.8 hours (95% confidence interval [CI] 2.2-3.4), doubles spontaneous lady partsl birth(relative risk [RR] 2.01, 95% CI 1.5–2.7) and halves the frequency of oxytocin use (RR 0.44, 95% CI 0.4–0.7), forceps use (RR 0.46, 95% CI 0.3–0.7),and cesarean delivery rate (RR 0.54, 95% CI 0.4–0.7). Women with labor support also reported higher satisfaction and a better postpartum course.

Conclusion

Labor support may have important positive effects on obstetric outcomes among young, disadvantaged women. Further studies on benefit relative to cost are needed before a broad-scale program is advocated.

Am J Obstet Gynecol 1999;180:1054-9

A comparison of intermittent and continuous support during labor: A meta-analysis

Kathryn D. Scott DrPH, Gale Berkowitz DrPH, Marshal Klaus MD

Abstract

Our goal was to contrast the influence of intermittent and continuous support provided by doulas during labor and delivery on 5 childbirth outcomes. Data were aggregated across 11 clinical trials by means of meta-analytic techniques. Continuous support, when compared with no doula support, was significantly associated with shorter labors (weighted mean difference –1.64 hours, 95% confidence interval –2.3 to –.96) and decreased need for the use of any analgesia (odds ratio .64, 95% confidence interval .49 to .85), oxytocin (odds ratio .29, 95% confidence interval .20 to .40), forceps (odds ratio .43, 95% confidence interval .28 to .65), and cesarean sections (odds ratio .49, 95% confidence interval .37 to .65). Intermittent support was not significantly associated with any of the outcomes. Odds ratios differed between the 2 groups of studies for each outcome. Continuous support appears to have a greater beneficial impact on the 5 outcomes than intermittent support. Future clinical trials, however, will need to control for possible confounding influences. Implications for labor management are discussed.

Also worth mentioning is that ACOG recently admitted that only a third of their recommendations are based on good and consistent scientific evidence.

http://journals.lww.com/greenjournal/Abstract/2011/09000/Scientific_Evidence_Underlying_the_American.3.aspx

And I know that ancedotal evidence can be taken with a grain of salt, but I've personally seen how epidural anesthesia prolongs the pushing stage of labor, how during this it can tire a woman out immensely, thus making the likelihood that she is going to have an instrumental delivery or even into OR a very real possibility.

Here are some studies supporting what I've personally witnessed:

Can Fam Physician. 2006 April 10; 52(4): 419-421

Does epidural analgesia increase rate of cesarean section?

Michael C. Klein, MD, CCFP, FAAP, FCFP

from their conclusion section: "EA given before the active phase of labour more than doubles the probability of receiving a CS."

Rates of caesarean section and instrumental lady partsl delivery in nulliparous women after low concentration epidural infusions or opioid analgesia: systematic review

E H C Liu, A T H Sia

BMJ 328:1410 doi: 10.1136/bmj.38097.590810.7C (Published 28 May 2004)

Data Synthesis Seven trials fulfilled the inclusion criteria for meta-analysis. Epidural analgesia does not seem to be associated with an increased risk of caesarean section (odds ratio 1.03, 95% confidence interval 0.71 to 1.48) but may be associated with an increased risk of instrumental lady partsl delivery (2.11, 0.95 to 4.65). Epidural analgesia was associated with a longer second stage of labour (weighted mean difference 15.2 minutes, 2.1 to 28.2 minutes). More women randomised to receive epidural analgesia had adequate pain relief, with fewer changing to parenteral opioids than vice versa (odds ratio 0.1, 0.05 to 0.22).

Conclusions Epidural analgesia using low concentration infusions of bupivacaine is unlikely to increase the risk of caesarean section but may increase the risk of instrumental lady partsl delivery. Although women receiving epidural analgesia had a longer second stage of labour, they had better pain relief.

Bottom line is that doulas can help mother's in labor. To state otherwise would be false. Women since the dawn of time have had their births attended by other women (and its only been in recent history have men attended and/or supported mom during birth) and the concept of having a doula is not a new one.

Additionally, epidural anesthesia does come with its own set of risks. There are many benefits to EA as well, some of which you wtbcrna, have pointed out. I also think to deny the many benefits of EA would also be a disservice to women and thats not my intention at all. However, we must properly educate women about the risks and benefits, and I believe that that needs to come well before she is in labor. I think the onus for providing true informed consent ultimately lies with the providers (OB/Gyn or midwife....with the anesthesiologist or CRNA reiterating these prior to performing the procedure), but women also need to properly educate themselves too and seek the answer to these very important questions. This dialogue and planning for birth needs to start early in the pregnancy.

Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.

Here is an interesting article:

Can Fam Physician. 2006 April 10; 52(4): 419–421. PMCID: PMC1481670

Copyright © 2006, Can Fam Physician

Does epidural analgesia increase rate of cesarean section?

Michael C. Klein, MD, CCFP, FAAP, FCFP

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.

Best Pract Res Clin Anaesthesiol. 2005 Mar;19(1):1-16.

Labor epidurals and outcome.

Gaiser RR.

SourceDepartment of Anesthesia, Pharmacology, Obstetrics and Gynaecology, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA. [email protected]

Abstract

The use of epidural analgesia for labor continues to increase dramatically. It has been suggested that epidural analgesia increases the risk of cesarean section, operative lady partsl delivery, and prolonged labor. These issues have been extensively investigated. The use of epidural analgesia does not increase the risk of cesarean section. It may affect the incidence of forceps delivery, but it depends on the medications used. Epidural analgesia does prolong labor, although the clinical significance of this prolongation has not been shown.

My words in bold: Another thing to consider is that women who have epidurals containing Fentanyl are more likely to have breastfeeding difficulties or failure, something that most anesthesiologists (and OBs) don't consider, as this is not something that directly affects them in the immediate. They don't see the longterm results of epidural use as it affects the infant, and the maternal/child bond of breastfeeding.

Int Breastfeed J. 2006; 1: 24.

Published online 2006 December 11. doi: 10.1186/1746-4358-1-24 PMCID: PMC1702531

Copyright © 2006 Torvaldsen et al; licensee BioMed Central Ltd.

Intrapartum epidural analgesia and breastfeeding: a prospective cohort study

Siranda Torvaldsen,1,2 Christine L Roberts,2 Judy M Simpson,3 Jane F Thompson,4 and David A Ellwood5

Abstract

Background

Anecdotal reports suggest that the addition of fentanyl (an opioid) to epidural analgesia for women during childbirth results in difficulty establishing breastfeeding. The aim of this paper is to determine any association between epidural analgesia and 1) breastfeeding in the first week postpartum and 2) breastfeeding cessation during the first 24 weeks postpartum.

Methods

A prospective cohort study of 1280 women aged ≥ 16 years, who gave birth to a single live infant in the Australian Capital Territory in 1997 was conducted. Women completed questionnaires at weeks 1, 8, 16 and 24 postpartum. Breastfeeding information was collected in each of the four surveys and women were categorised as either fully breastfeeding, partially breastfeeding or not breastfeeding at all. Women who had stopped breastfeeding since the previous survey were asked when they stopped.

Results

In the first week postpartum, 93% of women were either fully or partially breastfeeding their baby and 60% were continuing to breastfeed at 24 weeks. Intrapartum analgesia and type of birth were associated with partial breastfeeding and breastfeeding difficulties in the first postpartum week (p

Conclusion

Women in this cohort who had epidurals were less likely to fully breastfeed their infant in the few days after birth and more likely to stop breastfeeding in the first 24 weeks. Although this relationship may not be causal, it is important that women at higher risk of breastfeeding cessation are provided with adequate breastfeeding assistance and support.

Specializes in Anesthesia.
The first three studies you posteddid not prove or disprove what you were arguing. Did you read what you posted? The first study examined passive descent vs. Immediate second stage pushing. The second study was only examining Women's PRENATAL opinions of epidural use, and the third examined the relationship between epidurals and spontaneous lacs.

Only the last study really addressed what you were arguing - that epidurals don't increase the incidence of instrumental deliveries or C/S. For that one study you posted that states it does not, I'm sure I can find one that does. Let me go look...

The first study showed an additional benefit to epidurals (passive descent). The second study showed the women most likely to get an epidural (the most educated). The last study showed that in over 94 thousand patients there was no increase in C-sections or instrument delivery when patients have epidurals. There are tons of studies out there showing the exact samething. All that is out there that shows possible negative effects of epidurals is opinion pieces, small underpowered studies, and/or poorly designed/skewed studies.

I know exactly what I posted and the fact is epidurals do not cause increased c-sections or instrument deliveries. Anyone telling their patients that they do is wrong, and doing a disservice to their patients. The only thing that epidurals have been shown to do that may negatively impact delivery is that epidurals can increase overall delivery time. The reason epidurals increase delivery times slightly, an hour or so from the last study I read, is the patient is usually not ambulatory anymore and having the patient labor down/passively descend instead of pushing right away.

The simple fact is if epidurals increased c-sections or instrument deliveries we would use another method for analgesia for delivery or none at all.

If you want to debate research post some articles or at least debate the merits/methods/results of the ones I posted (which you did not).

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