Epidural analgesia for labour

Abstract

Epidural analgesia in labour From Miss J Towler, Midwife, and Mr A H C Walker, Consultant Obstetrician & Gynaecologist, St Mary's Hospital, Manchester M13 OJH Dear Sir, Andrew Doughty's paper (December 1978 Journal, p 879) expresses a contemporary anaesthetist's view on this important subject and concludes that 'an epidural rate of 40O% might be considered as really necessary'.. A 40% epidural rate might be necessary for cases of induced and accelerated 'pharmacological' labour, because the hypoxia due to the sudden and increased amplitude of the Syntocinon (oxytocin) contractions certainly increases the pain felt by the mother. Dr Doughty writes of the 'severe pain' experienced in labour, but we suggest that a mother who does experience severe pain (requiring relief by an epidural), does so because she is in the cold, clinical, strange surroundings of a labour ward and consequently is suffering from loss of autonomy and identity; in addition to which, she may have been subjected to an amniotomy, to an oxytocic infusion, to the application of a fetal scalp electrode and tocograph belt attached to a monitor. She is, consequently, literally 'confined' to a wet bed and will be almost totally dependent on her attendants. All these factors increase anxiety and, therefore, perception of pain. Dr Doughty concedes that the epidural 'deprives the mother of the automatic desire to bear down', but suggests that a 'spontaneous delivery' can be anticipated 'despite the use of regional analgesia'. The manoeuvres for this include 'improving the strength of uterine contractions with oxytocin', 'digital assistance of the rotation of the fetal head', and 'judicious application of fundal pressure' (which could cause placental separation), which he calls 'active management of the second stage with a view to securing a normal delivery'. To our minds, nothing could be more abnormal, and it is certainly the very opposite of 'spontaneous'. It is no wonder that it has been said that 'childbirth is not now something women do, but something done unto them by doctors'. We do, of course, concede that an epidural is valuable in selected cases, but it is still very important to remember that pregnancy is a 'nine months physiological disease, with a spontaneous cure, nine times out of ten'. Unfortunately, modern obstetric thinking ignores this definition. If one allows spontaneous onset of labour and first-stage ambulation, thus facilitating descent of the head (conversely, the supine wedged position for an epidural prevents this), and physiological contractions throughout, the patient often will require only Entonox (nitrous oxide and oxygen), the oxygen content of which must be beneficial for the fetus, it must aid the uterus to work more efficiently and it will relieve discomfort by reducing hypoxia. Dignity is very important, but so is a sense of achievement, and there can be dignity in achievement. Yours sincerely