Do Epidural's result in more C-sections or birth complications?

As an expectant father, my wife and I have been attending prenatal classes in anticipation of our first little one. Over the last couple weeks the topics of discussion have largely centred around interventions commonly used in the birthing process. These include oxytocin, epidural anesthesia, forceps, vacuum extraction, and C-section among others. Fear and confusion tend to be the common sentiments of most of the expectant parents (ourselves included) and so the intent of this entry is to help bring some clarity and understanding.

As a physician shared and informed decision making is my goal when discussing treatment options with patients. In order to do this effectively, we need to have an understanding not just that treatment "A" will increase risk for outcome "B", but more importantly by how much will it be able to do so. For example, if someone were to tell you that taking an aspirin a day would decrease your risk of having a heart attack, you'd likely think you should do it, despite the fact that it can cause GI bleeding. But what if the amount that it decreased your risk was only by 0.5% (ie from 8% to 7.5% risk over the next 10 years)? Then, when faced with how small the benefit it, you may decide otherwise. The key is having some sort of context for quantifying the risk or benefit, not just a statement that something may help or harm.

In order to get some answers, I spent some time reading research articles that asked the questions "do epidurals increase the risk of needing more medical intervention", and "do epidurals result in adverse outcomes for mothers and babies?". Before discussing what I've found, I should state that as a Naturopathic Doctor I do not have expertise in the area of obstetrics, nor do I deliver babies. The research I've done is that of someone who has a personal interest in the questions being asked, and a reasonable amount of expertise in interpreting scientific data. I should also state that as a naturopath, my bias would be toward avoiding unnecessary interventions. I also want to state that the following discussion is for women who are on their first baby, and who are not induced. I'll do this in three sections: no difference category, increased risk category, and increased benefit category. That said, here we go!

1. No difference.

The higher quality trials I looked at, and the meta-analysis (a statistical pooling of a bunch of separate trials) suggest that there is no increased risk of having a c-section for women receiving an epidural. There was also no difference noted in neonatal outcomes as evidenced by their apgar scores. One study of interest looked at a hospital in Missouri that compared groups of women giving birth before and after the hospital gave on-demand epidural service. They found that monthly total c-section rates were the same before and after they were made available on demand, indicating that increased rates of epidurals didn't increase the total rate of c-sections. Interestingly, when they looked more closely at the patients who had epidural on demand, they found that the women who were having dystocia tended to be the ones that were asking for epidurals. What they concluded was not that epidurals increased rates of c-section, but rather women who were already having difficulty with their labour tended to be the ones who requested epidurals. In that instance, it was difficulty labouring that resulted in higher c-section rates vs the epidural being the cause. Another question of interest is will an epidural increase risk for long term backache? Again, no difference.

2. Increased risks.

As for increased risks from epidural anesthesia? The consensus among most of the studies I read were that epidurals did 2 things: 1 - prolonged the second stage of labour by an average of 15-30 minutes; and 2 - increased risk for needing instrumentation (forceps, or vacuum extraction). Estimates range from anywhere between a 25-38% increase in risk relative to those who don't have an epidural. That may initially sound high, but to get a sense of what that really means you need to know what the risk is to start with. For example, if in most normal circumstances the risk of needing instrumentation for delivery is about 10%, an epidural would increase it to between 12.5%-13.8% (10% base risk, plus 25% of that 10%, which is 2.5%). Think of it like money: if your initial risk is $10, and you increase that by 25%, your total risk would be $12.50.

Serious adverse events are also possible with any intervention, however these tend to be rare. One study in the UK looked at the previous 500,000 births involving epidurals. They reported 108 events, of which 5 resulted in a permanent disability.

3. Benefits.

Interestingly, when women are polled after their birthing experience, satisfaction rates among women tended to be higher in the groups that had epidurals.

Conclusions.

Through my cursory reading of some of the literature surrounding epidurals and childbirth, I've learned that epidurals are a reasonable and relatively safe form of coping with pain in labour. Although there are always risks associated with such interventions in the short term (many of which were not addressed here), overall they don't seem to increase the need for c-section in most normal circumstances, or cause serious long term complications to mother and baby. I hope this has helped dispel some confusion and quantify some of the risks. It certainly has for me.

Regards,

Bryn

What's the difference between wheat allergy, gluten allergy, and celiac disease?

There is confusion among many people surrounding the question of celiac disease, wheat and/or gluten allergy. Perhaps I can help shed some light.


First, Celiac disease is an autoimmune reaction that is triggered by exposure to gluten. What this means is that when your body sees gluten, it starts attacking itself - primarily in the small intestine, but also in other parts of the body. Symptoms can include bloating, chronic diarrhea, irritable bowel syndrome, constipation, skin rash, and other disease states such as anemia, hypothyroidism, and osteoporosis. Diagnosis can be tricky as there is no one perfect diagnostic test. There are a couple blood tests that are pretty good provided you've been eating gluten regularly for the couple weeks preceding the test. The other test is via a biopsy, where they actually go in to the small intestine and take a tissue sample. This is considered to be the "gold standard" among many clinicians, however it's still not 100%. A third option (and one gaining some momentum in the evidence circles) is to use a genetic test to aid in diagnosis. There are a couple genes that when present can give you an estimate of your lifetime risk of developing celiac disease (the DQ2 and DQ8 alleles). One of the benefits of this test is that if you DON'T have the genetics, you don't have celiac disease.


Second, food allergies and sensitivities (in this case wheat or gluten) can lead nebulous discussion on semantics. One type of allergy is the classic "eat a peanut and your throat swells closed and you die" type reaction. Those are well defined and understood. As for the rest, let's just call them "having an undesirable reaction to a food". These are less well understood, but still problematic for many people. For more info, see my previous post entitled "Are blood tests for food allergies a waste of time".


So given these two scenarios, what now? Barring laboratory diagnosis, a clinically useful option is to eliminate gluten (anything containing wheat, rye, barley, or oats) completely from the diet and to watch for symptomatic improvement. There is debate on how long one should abstain - anywhere from a few days to 6 months, but that should be tailored to the patient by the clinician depending on a number of factors. If there is an improvement in symptoms, that's your first clue. If not, it's not likely the culprit. If you notice an improvement, the next step is to challenge the food you suspect.


To distinguish between wheat and gluten as a problem, you can start by challenging rye or barley. These both contain gluten, but are not wheat - hence if you note a reaction, it's from the gluten. If that's ok, then challenge wheat. If that is a problem you have your answer. When challenging foods it's best to use that particular food in it's purest form ex/ cream of wheat (for wheat), or straight barley. This helpful because in bread for example, there are a number of other ingredients you may be reacting to. These types of diagnostic experiments are best done with the help of a health provider you trust, to ensure they're being done properly.


Since the treatments for allergies and intolerances are the same (avoidance of your problem food), does it really matter what one calls the problem?  In my opinion it does,  as accurate diagnoses are the hallmark of good medical care and decision making.  Food "allergies" and celiac disease have significant differences in long term health outcomes, so knowing what one is up against is an important step.


Speak soon,


B