Commentary on Nystedt A., Edvardsson D. and Willman A. (2004) Epidural analgesia for pain relief in labour and childbirth – a review with a systematic approach. Journal of Clinical Nursing 13, 455–466
Article first published online: 18 AUG 2004
Journal of Clinical Nursing
Volume 13, Issue 6, pages 779–781, September 2004
How to Cite
Mander, R. (2004), Commentary on Nystedt A., Edvardsson D. and Willman A. (2004) Epidural analgesia for pain relief in labour and childbirth – a review with a systematic approach. Journal of Clinical Nursing 13, 455–466. Journal of Clinical Nursing, 13: 779–781. doi: 10.1111/j.1365-2702.2004.00931.x
- Issue published online: 18 AUG 2004
- Article first published online: 18 AUG 2004
This paper by Nystedt et al. constitutes a welcome attempt to review systematically the literature on epidural and other forms of regional analgesia in labour. The authors seek to answer the question of whether and to what extent the midwife is able to recommend this form of pain control to the childbearing woman.
The aim, which the researchers spell out clearly, relates to the ‘effects and risks’ associated with epidural analgesia in labour. The question, which immediately springs to mind, though, is whether and how their review differs from the Cochrane Systematic Review by Howell (2004). It is uncertain whether it does differ in any significant respect. While Howell (2004) aims to focus on ‘the effects of epidural analgesia on pain relief and adverse effects in labour’, Nystedt et al. seek to review the ‘effects and risks’. Howell's review is explicit in its intention to compare epidural and other pain control methods. For Nystedt et al., this comparative approach is implicit; particularly in view of the relatively small proportion of childbearing women in westernized societies who give birth without the benefit of any pain control method.
While accusations of reinventing the wheel may be starting to appear appropriate at this point, the review by Nystedt et al. actually does prove to be subtly different. This may be because these researchers set out with the intention of providing information for midwives to pass on to childbearing women. The Cochrane Library, however, has a wider remit, which results in an approach, which is less-specifically oriented towards women. Nystedt et al. focus on the aspects of epidural analgesia relating to ‘maternal satisfaction, dystocia, caesarean, neonatal condition and breastfeeding’. It has to be agreed with the authors that these are aspects, which are likely to be helpful in informing the woman's pain control decision-making.
A major problem that arises in this paper, though, emerges out of one of these aspects. It is the one, which the authors entitle ‘dystocia’. This is a term and concept with which some may be unfamiliar. I first became acquainted with it and its antonym, eutocia, as a student midwife. My acquaintance then lapsed until I became concerned about the depressant effects of chloroform on uterine contractions (Mander, 1998). This not inconsiderable lapse of time indicates the relative infrequency with which this term is used in the UK.
This word has been defined as ‘difficult delivery or parturition’ (Dark, 2003). This definition is less than helpful, as women not infrequently indicate that labour may be challenging. While the term itself is not commonly used in the UK, when it is used the meaning tends to be more precise. Its rare use and its UK meaning is reflected in the scant attention given to this topic in the relevant chapter in what is probably the major UK-based midwifery textbook (Shiers, 2003, p. 540). This source states ‘dystocia literally means ‘‘difficult labour’’ and is associated with slow progress or failure to progress in labour’.
The equivalent North American textbook, however, addresses ‘dystocia’ at length and offers a subtly different, i.e. considerably broader, definition: ‘Dystocia is defined as a long, difficult or abnormal labour. It is caused by dysfunctional labour, pelvic abnormality, abnormal presentation, maternal position, psychologic responses in mother.’ (Lowdermilk & Perry, 2004, p. 996).
Thus, the UK term is relatively narrow, indicating lack of progress, which, unlike its North American counterpart, is of unknown origin. The North American concept seeks to encompass a wide range of variably physical, psychosomatic and psychological causes of labour being perceived to progress inadequately.
In view of this apparently fundamental difference, I searched CINAHL to find journal publications which would inform this issue. My search produced 91 items incorporating the word ‘dystocia’. The majority (52) of these items referred to a potential obstetrical emergency involving the birth of the baby's shoulders. Of the remainder, which referred to the labour, 35 were North American, one was historical and only three originated in the UK. This search clearly supports my initial impression that ‘dystocia’ is a term widely, even loosely, used in North America. There it has a considerably less precise meaning than that which it conveys in the UK.
The Swedish authors of this paper on epidural analgesia should have taken the simple precaution of defining their meaning of the term ‘dystocia’. This meaning is crucial because Nystedt et al. refer frequently to the association between dystocia and epidural analgesia. This association, as befits such an obscure term, is also less than clear.
It was further surprising to find that these authors had separated dystocia in their findings from caesarean. In the UK it is usual for this phenomenon, more commonly known here by the unfortunate title ‘failure to progress’, only to be diagnosed as an indication for caesarean. This diagnosis, however, may be a medical artefact, which serves to deny the huge variation in the rate of progress of uncomplicated labour, dependent as the diagnosis is on the use of the partogram. The crucial, not to say iatrogenic, role of the partogram in the development and diagnosis of dystocia is becoming more widely recognized (Albers, 2001).
Further, Nystedt et al. are less than clear about the relationship between epidural analgesia and dystocia. They suggest that an epidural may actually be administered to ‘correct’ dystocia. This suggestion conflicts with the prevailing evidence, as Howell (2004) observes: ‘Epidural analgesia was associated with … longer first and second stages of labour’. This association is usually considered to be that the epidural causes the labour to become slower in view of the ‘increased incidence of fetal malposition’.
They further complicate the issue by continuing the argument that the abnormal labour may ‘precede’ the administration of the epidural. This is not entirely rational, unless one believes that the existence of an ‘epidural on demand’ service actually increases the number of women experiencing an abnormal labour. If this scenario applies, it is necessary to question how it is assessed and recorded and why this abnormality is not treated, rather than having an epidural administered.
The authors seek to blame the association between epidural and prolonged labour on nulliparity (first time motherhood). This assertion stretches the bounds of credibility. Nystedt et al. choose to ignore the possibility that the epidural, rather than nulliparity, may be both the cause of the dystocia and the indication for the caesarean.
In spite of the term ‘dystocia’ proving seriously problematical in these researchers’ review, they admit that the findings of their review are less than clear cut. On the basis of this lack of clarity they conclude that ‘midwives and doctors can recommend this form of pain relief’. The audacity of such a suggestion is barely credible for a number of reasons. Most obviously, as the research evidence is regarded as less than helpful, no recommendation should be being made by any health care professional who aspires to evidence based practice. It may, though, be that this finding is unlikely to prevent our medical colleagues from recommending this potentially iatrogenic intervention. It has been observed that they have their own agenda (Mander, 1993).
The situation for the midwife is crucially different. This difference should have been recognized by these researchers who work in a country with a strong tradition of midwifery care. The midwife strives to identify a strong evidence-base for her practice and her care of the woman in labour. It is necessary to recognize that there are some areas in which authoritative evidence is insufficient, especially in those areas relating to midwifery interventions.
More importantly, though, these researchers should have recognized that the midwife would not be in a position to ‘recommend’ this or any other intervention to the woman or the couple. The midwife would, at best, be able to present the childbearing woman with the most authoritative research or other evidence, which is available. The midwife would then support the childbearing woman in the choice, which the woman makes on the basis of her own unique knowledge. This supportive role would apply to the method, which the woman uses to control her pain in labour, or any other decision, which the woman makes in relation to her care.
This serious research attention to epidural and other regional forms of analgesia in labour is most welcome. As Nystedt et al. correctly observe, more and more accurate information is essential for childbearing women and their partners to make well-informed decisions about pain control in labour.
The immense attraction of epidural analgesia for childbearing women, for researchers and for health care providers is easily apparent. The extent to which this attraction is based on research evidence is less easy to understand. Although Nystedt et al. have attempted to probe the research evidence, their attempt has been confounded by the labyrinthine terminology. The value of their work has been further jeopardized by misunderstanding the role of the midwife.
In view of these difficulties, researchers, health care providers and childbearing women might be well-advised to redirect their attention on to a pain control method without the iatrogenic potential which epidural analgesia brings. There is such a method which, additionally, has the advantages of being relatively cheap, relevant to a midwife-friendly health care system such as Sweden's, and proven effective by a long series of authoritative RCTs. This pain control method comprises, quite simply, the psychosocial support offered to the childbearing woman in labour by another woman (Mander, 2001).
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