Epidural Service Research Articles

Nurses' perception of epidural services in a Johannesburg academic setting.

Labour pain is associated with detrimental maternal and foetal physical and psychological effects. Labour analgesia is a basic right for all women and labour epidural analgesia has been accepted as the gold standard for providing such, with reported improvement in patient satisfaction. In South Africa, studies have shown that labour epidural rates are low. At an academic hospital in Johannesburg, a 24-h labour epidural service combined with an awareness campaign and educational programme (LEAP) was initiated with the aim of improving labour epidural rates. Results showed a short-lived uptake with a subsequent decline. This study explored the experiences of labour ward nursing staff regarding the labour epidural service at this academic hospital including perceived limitations and possible recommendations regarding improving service provision. A qualitative, descriptive and exploratory study was conducted. Purposive sampling was used with semistructured, audio-recorded individual interviews, thematic analysis was performed using Braun and Clarke's six-phase approach. The key theme is required education and supervision of epidural insertion (see page 3), management of childbirth and challenges related to epidural service provision. A positive sentiment was expressed by the participants; however, deficiencies in the service such as shortages of experienced personnel, work constraints and insufficient training may be affecting service sustainability. Further studies are recommended to form guidance towards the development and implementation of interventions to improve service delivery.Contribution:Provision of continual training and increased staffing of healthcare personnel will help improve the sustainability of the labour epidural service.

Knowledge and Attitude about Labor Epidural Analgesia among Pregnant Women Attending Antenatal Clinic.

Labour pain is one of the most painful experiences that a woman faces in her lifetime. There are various options for labour pain management. Epidural analgesia is the gold standard method for pain management during labour. In developing and under-developed countries there are many challenges to provide this service, a very important one being knowledge about epidural analgesia among the parturients and the physicians. A prospective cross-sectional study was carried out among 384 pregnant women attending Antenatal clinic of a tertiary level teaching hospital using pretested structured questionnaire prepared by a team of anaesthesiologists and obstetricians. Non-probability purposive sampling technique was used. The data was analysed by using SPSS version 20.0. Descriptive and inferential statistical methods were used for analysis. Of the 384 pregnant women, only 29.4% had knowledge about some form of labour analgesia techniques and only 16% of the participants were aware of labour epidural analgesia. Also, only 6.2% were aware that epidural service is available at our hospital. Regarding acceptance, only 42.4% were willing to use epidural analgesia in their present pregnancy. The present study findings revealed that a significant number of participants had very limited knowledge about labour epidural analgesia and were also unaware of the availability of the service in our hospital. Educational programs need to be provided to all the pregnant women for enhancement of knowledge and awareness about epidural labour analgesia to increase its acceptability among them.

Establishment of Labor Epidural Analgesia Service and its Assessment: An Experience in a Hospital of a Middle-Income Country.

Even though the idea of painless birth is more than 100 years old, it is still underrepresented in some parts of the world despite progress in science, education, anesthesia, spinal and epidural needles, development of catheters, new drugs, and infusion pumps. Maternal care should basically be the safety of the patient (in this case two patients) and also provide all kinds of protection in the form of a multidisciplinary team with an anesthesiologist, especially when it comes to pain therapy and anesthesia for women in labor. In this direction, our hospital departments with low or moderate volume of annual births made the decision to educate ourselves for painless childbirth and contribute more to the care of women in labor. The enthusiasm and dedication of our clinical team prevailed and today we have a high standard of labor epidural service. The aim of this study was to evaluate the establishment of the epidural labor service by comparing the effects of epidural analgesia on labor pain and the course of labor. The secondary objectives were to compare satisfaction with epidural analgesia and the impact of epidural analgesia on the delivery mode. This was a prospective observational hospital-based study conducted on100 patients after the establishment of epidural service. Parturients who were signed to receive epidural analgesia formed Group A and parturients who did not request epidural analgesia formed Group B. All parturients are induced in the delivery room with a Bishop score of 5 or higher. Pain intensity measured through the visual analog scale of pain (VAS score) was significantly lower in Group A (n = 46) compared to Group B (n = 50) at measured points of time (p<0.001). There was a fall in the mean VAS score in Group A from 7.94 to 3.86 within 20 minutes of the bolus dose and starting a continuous infusion.Labor progress according to the Bishop score and till the end of the second stage of labor, or to the transfer to the operating theatre, according to the monitored time in Group A was 176 minutes and it was lower in Group B with 155 minutes; however, by test of linearity we do not gain significance(p = 0.2). There were eight parturients in each group(17% vs 16%) who were indicated for surgical delivery. According to Pearson's correlation test for the outcome of labor between parturients receiving epidural analgesia and parturients without epidural analgesia (p = 0.8), we cannot say that epidural analgesia in labor is correlated with the outcome of surgical delivery. Establishing a new hospital procedure such as an epidural painless service for childbirth in low or moderate-volume settings of annual births is very challenging. By evaluating epidural labor services in our hospital, we created the best environment for continuous improvement and long-term efficacy and safety of our analgesic techniques aimed at providing excellent care to mothers and their babies.

Investigating Determinants for Woman's Choice to Accept An Epidural for Labour Analgesia at The Delivery Unit of The Tamale Teaching Hospital

The epidural labour analgesia service at the delivery unit of the Tamale Teaching Hospital has recorded low patronage. Low patronage of epidural labour analgesia in poor resource Countries could partially be attributed to lack of awareness, limited resources or lack of equipment such as patient monitors, local anaesthetics or analgesics and overwhelming patient numbers. This study aimed to assess factors that influence epidural labour analgesia acceptance or refusal at the maternity unit of the Tamale Teaching Hospital.

Awareness and perception of epidural labor analgesia among pregnant women visiting antenatal clinic in National Referral Hospital

Aims: To assess the awareness and perception of labour epidural analgesia among pregnant women visiting the antenatal clinic.&#x0D; Methods: This was an observational cross-sectional study. Study participants included pregnant women visiting the antenatal clinic during 2nd and 3 rd trimester conducted from 21 st September 2018 till 20 th September 2019. Data were collected by using an interviewer-administered questionnaire. Ethics approval was granted by the research Ethics Board of health, Bhutan.&#x0D; Results: Total 450 parturients participated in this study; 61.4% of the participants knew that labour epidural services were available and 37.5% got information through media. A total of 57.3% of respondents had severe fear about labour pain; 62.4% had severe fear about delivery complication; 85.2% thought that epidural labour analgesia was a good method of pain relief; and 67% were willing to accept it for their current pregnancy. However, 86.6% would recommend epidural labour analgesia as an option of pain relief to other pregnant women.&#x0D; Conclusion: Awareness about the availability of labour epidural analgesia services needs to be improved, as a majority of the parturient was keen to avail epidural analgesia after the information about its availability was provided.

Labour epidurals in Gauteng Province, South Africa

Background. Inadequately controlled labour pain is associated with numerous deleterious physiological and psychological effects. Epidural labour analgesia is accepted as the gold standard. Objectives. To establish the frequency of labour epidural analgesia for vaginal and caesarean section delivery in Gauteng Province (GP) private and public hospitals. Methods. GP maternity hospitals belonging to the three largest private hospital groups, and public academic, tertiary, regional and district maternity hospitals, were approached for inclusion in the study. A total of 24/47 private hospitals and 21/26 public hospitals agreed to participate in the present study and data from these hospitals were included in the data analysis. This was a retrospective study, and the delivery statistics and registers for 2015 were examined from all participating hospitals. Consecutive convenience sampling was applied. Results. A total of 3 560 labour epidurals were placed in the 45 participating hospitals in GP in 2015. About two-thirds (62%; n =2 208) of these labour epidurals were placed in the private sector. The median (interquartile range (IQR)) annual epidural frequency for all participating private hospitals was 6% (1.37 - 8.42). Only two public hospitals in GP were able to offer labour epidural services in 2015 and the annual proportion of deliveries with epidural placement was 4.1%. Both hospitals were academic hospitals affiliated with a single university. Conclusion. Similar to other developing countries, the labour epidural rates in GP hospitals were well below international labour epidural rates in 2015. This lack of service provision may be compromising patient care as well as the training of healthcare professionals.

An audit of the labour epidural analgesia service at a regional hospital in Gauteng Province, South Africa

Background. Neuraxial analgesia in the form of a labour epidural has been shown to be the most effective analgesic strategy for the labouring mother. In developed countries, data are readily available as to the number of women receiving labour epidural analgesia, as well as the complication rates of labour epidurals. However, data for South Africa (SA) on labour epidural analgesia services are limited, and there were no published data for Rahima Moosa Mother and Child Hospital (RMMCH), Johannesburg, SA. Objective. To describe the labour epidural analgesia service at RMMCH over the period of 1 year. Methods. A retrospective audit using consecutive convenience sampling was done reviewing all epidural records at RMMCH from 1 January to 31 December 2014. Results. During the study period, labour epidural analgesia was administered for 187 (1.6%) of 11 853 deliveries. Epidural records were collected for all administered labour epidurals. The most common indications documented were labour analgesia (41.7%) and primigravida (28.9%). Labour epidurals were not administered for specific medical conditions. The incidence of complications was 22.6%, and these were minor and self-limiting. Hypotension was the most common complication (12.3%). Patient satisfaction with labour epidural analgesia, where documented, was high (98.4%). Conclusion. This audit revealed a low incidence of labour epidural analgesia at RMMCH during the study period. The incidence of complications was in keeping with that seen in developed countries. Poor documentation was noted to be a problem.

Report on Implementation, Use, and Sustainability of a Labor Epidural Service in Georgetown, Guyana

The use of epidural analgesia for laboring women is generally unavailable at public hospitals in Guyana despite favorable utilization rates in private institutions. In 2014, a healthcare team completed a targeted mission aimed at neuraxial analgesia training of providers at the preeminent public hospital in Georgetown, Guyana. This study evaluates the impact of the training, including provider attitudes, use, and barriers. A prospective, mixed methods study of all obstetric, nursing, and anesthesiology providers at Georgetown Public Hospital Corporation was completed. Quantitative assessment of the posttraining use of epidural analgesia at 2 and 6 months was documented. Provider surveys were distributed anonymously at 2 months posttraining. Targeted interviews were completed from a random sampling of providers at 6 months; qualitative analysis of interviews formulated the basis for reporting limitations and barriers. Providers surveyed included 7 anesthesia providers and 24 obstetrics providers. Respondents believed Guyanese women should be offered epidural analgesia (93%), epidurals could be performed safely (87%), and Guyana has the resources necessary for routine use (81%). In assessing epidural knowledge, anesthesia providers achieved 60% correct response rate compared to 84% among obstetrics providers. Nurse anesthetists placed 16 epidurals following training. However, placement ceased after 2 months. The largest barriers to placement were unavailable anesthesia staff (63%), lack of supplies (16%), and insufficient nursing staff to monitor patients with epidurals (11%). A 1-week mission achieved widespread Guyanese provider acceptance despite a lack of previous experience. However, barriers proved insurmountable to achieving a sustainable, independently functioning epidural analgesia program.

Increasing the labour epidural rate in a state hospital in South Africa: challenges and opportunities

AbstractBackground: A 2012 audit on labour epidural analgesia rates in Tygerberg Hospital (TBH) revealed that only 2.2% of labouring parturients received epidural analgesia. This unacceptably low number necessitated a dedicated epidural service that was subsequently initiated in June 2014 by the Department of Anaesthesiology and Critical Care to improve the quality of care in labouring patients.Methods: A retrospective follow-up audit was conducted from June 2014 to December 2015 and included data on epidural rates, indications, complications and patient satisfaction. Comparison was made with the 2012 data to evaluate the impact of change on care provided and to recommend future changes.Results: Labour epidural rates improved to 5.16% for the audit period, with 2014 and 2015 rates of 7.44% and 3.89% respectively. Daytime epidurals doubled in 2014/2015 and complication rates decreased from 32.3% in 2012 to 16%. Primary indications for epidural analgesia included pre-eclampsia, morbid obesity, primigravidit...

Epidural analgesia during labour – maternal understanding and experience – informed consent

Women obtain information on epidural analgesia from various sources. For epidural for pain relief in labour this is provided by the anaesthetist as part of the consenting process. There is much discussion about the inadequacy of this consenting process; we report on women's knowledge, experience and recall of this process at a regional hospital with a 24-h epidural service. Fifty-four women were interviewed within 72 h of a vaginal birth. 91% of the women had acquired information from friends, relatives and antenatal classes. Lack of recall of benefits of epidural analgesia accounted for 26 (38%) and 25 (26%) of the responses, respectively. Similarly in terms of amount of pain relief they could expect, 13 (21%) could not remember and 13 (21%) thought that it may not work. We suggest use of varying methods of disseminating information and wider utilisation of anaesthetists in the antenatal educational programmes.

Early versus late initiation of epidural analgesia for labour.

Pain during childbirth is arguably the most severe pain some women may experience in their lifetime. Epidural analgesia is an effective form of pain relief during labour. Many women have concerns regarding its safety. Furthermore, epidural services and anaesthetic support may not be available consistently across all centres. Observational data suggest that early initiation of epidural may be associated with an increased risk of caesarean section, but the same findings were not seen in recent randomised controlled trials. More recent guidelines suggest that in the absence of a medical contraindication, maternal request is a sufficient medical indication for pain relief during labour. The choice of analgesic technique, agent, and dosage is based on many factors, including patient preference, medical status, and contraindications. There is no systematically reviewed evidence on the maternal and foetal outcomes and safety of this practice. This systematic review aimed to summarise the effectiveness and safety of early initiation versus late initiation of epidural analgesia in women. We considered the obstetric and fetal outcomes relevant to women and side effects of the treatments, including risk of caesarean section, instrumental birth and time to birth. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (12 February 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 1), MEDLINE (January 1966 to February 2014), Embase (January 1980 to February 2014) and reference lists of retrieved studies. We included all randomised controlled trials involving women undergoing epidural labour analgesia that compared early initiation versus late initiation of epidural labour analgesia. Two review authors independently assessed trials for inclusion, extracted the data and assessed the trial quality. Data were checked for accuracy. We included nine studies with a total of 15,752 women.The overall risk of bias of the studies was low, with the exception of performance bias (blinding of participants and personnel).The nine studies showed no clinically meaningful difference in risk of caesarean section with early initiation versus late initiation of epidural analgesia for labour (risk ratio (RR) 1.02; 95% confidence interval (CI) 0.96 to 1.08, nine studies, 15,499 women, high quality evidence). There was no clinically meaningful difference in risk of instrumental birth with early initiation versus late initiation of epidural analgesia for labour (RR 0.93; 95% CI 0.86 to 1.01, eight studies, 15,379 women, high quality evidence). The duration of second stage of labour showed no clinically meaningful difference between early initiation and late initiation of epidural analgesia (mean difference (MD) -3.22 minutes; 95% CI -6.71 to 0.27, eight studies, 14,982 women, high quality evidence). There was significant heterogeneity in the duration of first stage of labour and the data were not pooled.There was no clinically meaningful difference in Apgar scores less than seven at one minute (RR 0.96; 95% CI 0.84 to 1.10, seven studies, 14,924 women, high quality evidence). There was no clinically meaningful difference in Apgar scores less than seven at five minutes (RR 0.96; 95% CI 0.69 to 1.33, seven studies, 14,924 women, high quality evidence). There was no clinically meaningful difference in umbilical arterial pH between early initiation and late initiation (MD 0.01; 95% CI -0.01 to 0.03, four studies, 14,004 women, high quality evidence). There was no clinically meaningful difference in umbilical venous pH favouring early initiation (MD 0.01; 95% CI -0.00 to 0.02, four studies, 14,004 women, moderate quality evidence). There is predominantly high-quality evidence that early or late initiation of epidural analgesia for labour have similar effects on all measured outcomes. However, various forms of alternative pain relief were given to women who were allocated to delayed epidurals to cover that period of delay, so that is it hard to assess the outcomes clearly. We conclude that for first time mothers in labour who request epidurals for pain relief, it would appear that the time to initiate epidural analgesia is dependent upon women's requests.

KNOWLEDGE, ATTITUDE AND USE OF PAIN RELIEF IN LABOUR AMONG WOMEN ATTENDING ANTE-NATAL CLINIC AT SHALOM COMMUNITY HOSPITAL, ATHI RIVER.

To find out the knowledge, attitude and practice of pain relief methods during labour among mothers attending antenatal clinics at Shalom Community Hospital, Athi River, Kenya. Cross Sectional study. Shalom Community Hospital, Athi River, Kenya. Two hundred and seven participants attending antenatal clinics at the facility were recruited. The median age of the participants was 28 years and a median parity of one. Most of the study participants, 89.4%, were not aware of any pain relief method during labour. Among the 10.6% patients that were of a pain relief method, 54% had gotten the knowledge from the doctors. All the patients had experienced pain in labour with 72% rating the pain as severe pain. Only 37% of the patients were offered a pain relief method and the intramuscular injectable was offered to all. Majority (88%) of those offered a form of pain relief rated the pain relief method as ineffective. A majority of the women 93% would use a pain relief method in the next labour with epidural method being the most preferred method. The level of knowledge of pain relief methods among mothers islow. There is need to integrate information on pain relief options in labour as part of antenatal services offered routinely. Epidural analgesia services should be enhanced.

Synthetic oxytocin and breastfeeding: Reasons for testing an hypothesis

Synthetic oxytocin is widely used in developed countries and in emerging countries as well. It is the most common medical intervention in childbirth. A great variety of side effects are plausible.There are in particular theoretical reasons to test the hypothesis that the increasing incidence of breastfeeding difficulties and the frequent earlier than desired cessation of breastfeeding are related to the use of synthetic oxytocin during labour.There have already been some studies that tend to support this hypothesis. Four hundred of the 7465 children born in 2006 at the Carlos Haya University Hospital (Malaga, Spain) were randomly selected. By interviewing the mothers, information about feeding type and duration was obtained in 2011 for 316 children. Among the 189 children who were born after labours induced or augmented with synthetic oxytocin, the odds ratio for bottle-feeding was 1.451 and the odds ratio for withdrawal at 3months was 2.294. In addition, the Battelle Developmental Inventory was used to assess at age five 148 children (84 born with synthetic oxytocin): the odds ratio for neuropsychological development disorders after use of oxytocin was 1.46.The main limitation of such a preliminary study is that in the context of a tertiary Spanish hospital the possible effects of synthetic oxytocin on the quality and duration of breastfeeding cannot be easily dissociated from the effects of other components of pharmacological assistance during labour, particularly epidural fentanyl (a synthetic opioid analgesic). This comment is valid for all studies exploring the side effects of synthetic oxytocin in obstetric units of developed countries, including explorations through videotapes of the effects of synthetic oxytocin on primitive neonatal reflexes. It is also valid for studies exploring the side effects of obstetric analgesia without taking into account the use of synthetic oxytocin.This is why we underline the importance of conducting such studies in emerging countries (e.g. China and Brazil) where synthetic oxytocin is widely used while there are no epidural services. Studies of oxytocin given electively at the onset of third stage of labour (after the birth of the neonate) should help to interpret possible effects on the quality and duration of breastfeeding.

Pregnant women’s awareness and acceptance of epidural anesthesia and its influence on cesarean section rate control in China: A qualitative study

Background: Epidural anesthesia, as an effective pain relief method, could be viewed as an attempt to encourage vaginal delivery and control cesarean section. Increased demand caused by psychosocial factors such as fear of childbirth and labor pain is supposed to be one predictable drive of high cesarean section rate in present China. Little qualitative information on women’s awareness and perceptions of epidural anesthesia was found, but conscious efforts should be focused on this part to help generate policy-making priority. Methods: This study was carried out under an exploratory descriptive design in Bao’an Maternity and Child Health Hospital. Those interested in participating would be invited to focus group discussion or individual interview according to a semi-structured open-ended guide after collecting the participants’ demographic characteristics. The thematic content analysis approach was used for data analysis. Results: Five major themes were identified: 1. the sources to gain information on epidural anesthesia; 2. clinical impact; 3. social impact on awareness; 4. association between epidural anesthesia and cesarean section; 5. attitudes and questions about the current service implementation. Discussions: The interplay between pregnancy knowledge, socio-economic conditions, social support, insurance policy environment, women’s judgment of health care quality influences the ways women acknowledge and utilize epidural anesthesia service. Conclusions: As maternal requested CS due to low pain tolerance emerges gradually, natural labor with epidural anesthesia is a more suitable childbirth option, which is also expected to function in reducing CS rate by service-providers and administrators in the health departments of China besides building up a pain-free labor environment.

Remifentanil Patient-Controlled Analgesia for Labour: A Complete Audit Cycle

Remifentanil patient-controlled analgesia (PCA) was introduced to a small maternity unit where an extensive epidural service was difficult to provide. This was a new service and the New Zealand College of Midwives had serious doubts about the efficacy and safety of remifentanil, so auditing its use was important. In a two-stage audit, clinical notes of 244 consecutive remifentanil users were studied between January 2008 and November 2009. We developed a questionnaire to assess the parturients' satisfaction with remifentanil PCA and designed a proforma to evaluate it against four standards of best practice. During the two audit periods, timely commencement of PCA was achieved in 65% and 82% of cases, respectively. A 70% compliance rate with monitoring standards fell to 10% after the withdrawal of supervision by an acute pain team, but improved to 91% following implementation of regular midwifery training sessions and a redesigned partogram and prescription flowchart. Ninety-four percent of women rated remifentanil PCA as excellent, very good or good. Maternal side-effects were nausea, pruritus and drowsiness. A comparison of Apgar scores of consecutive neonates born by normal vaginal delivery to women receiving no analgesia, with those born to women using remifentanil PCA, demonstrated no difference. As a result of our audit, remifentanil PCA is now viewed by our midwives as an effective and safe method when accompanied by 1:1 care and appropriate monitoring. With our input other maternity units have introduced it, especially where epidural service provision is limited, and for patients in whom epidural analgesia is contraindicated.

Audit of a ward-based patient-controlled epidural analgesia service in Ireland

Ward-based patient-controlled epidural analgesia (PCEA) for postoperative pain control was introduced at our institution in 2006. We audited the efficacy and safety of ward-based PCEA from January 2006 to December 2008. Data were collected from 928 patients who received PCEA in general surgical wards for postoperative analgesia using bupivacaine 0.125% with fentanyl 2 μg/mL. On the first postoperative day, the median visual analogue pain score was 2 at rest and 4 on activity. Hypotension occurred in 21 (2.2%) patients, excessive motor blockade in 16 (1.7%), high block in 5 (0.5%), nausea in 5 (0.5%) and pruritus in only 1 patient. Excessive sedation occurred in two (0.2%) patients but no intervention was required. There were no serious complications such as epidural abscess, infection or haematoma. Effective and safe postoperative analgesia can be provided with PCEA in a general surgical ward without recourse to high-dependency supervision.

A qualitative investigation of expectant and new mothers' understanding of the model of a stand-alone midwifery-led birth centre

ObjectiveTo determine understanding of the model of a stand-alone Midwifery led unit, in order to inform and develop education programs for potential users.DesignQualitative study using interviews.SettingDistrict General Hospital Maternity service.Participants10...

Informed consent for epidural analgesia in labour: a survey of UK practice*

Anaesthetists are legally obliged to obtain informed consent before performing regional analgesia in labour. A postal survey of consultant-led UK anaesthetic units was performed in September 2007 to assess practice regarding obtaining informed consent before inserting an epidural, and documentation of the risks discussed. The response rate was 72% (161/223). There was great variation between units regarding which risks women were informed about and the likely incidence of that risk. One hundred and twenty-three respondents out of 157 providing an epidural service (78%) supported a national standardised information card endorsed by the Obstetric Anaesthetists' Association, with all the benefits and risks stated, to be shown to all women before consenting to an epidural in labour.

A reply

Dr Scott has raised some interesting issues and I think these are worth exploring. Firstly, I refer Dr Scott to a review done the same year on the same topic with very similar references [1] to the one that he has quoted. It found very little benefit of epidural analgesia in colorectal surgery. The authors in the reference quoted by Dr Scott state that they were unable to comment on the increase or decrease in anastomotic dehiscence using thoracic epidural analgesia and also comment on the fact that many of the proposed benefits to epidural analgesia were unable to be proven [2]. So we do not believe that the evidence that he has provided supports the safety or efficacy of epidural analgesia in patients who have had colorectal surgery. Regarding the use of the study by Gould et al. [3], we chose this as it is the only study that we are aware of that has clearly demonstrated the relationship between cardiac output, blood pressure and gastro-intestinal tract perfusion. Gould et al. clearly showed that gut perfusion is not related to cardiac output but is related to an increase in perfusion pressure. Most therapies used to treat epidural induced hypotension are based on either fluid loading or decreasing the epidural infusion rate. Fluid loading will optimise cardiac output but will do very little to improve vascular resistance and relying on pain driven catecholamines to increase the blood pressure seems somewhat perverse. It is, of course, very difficult for us to comment on Dr Scott’s 3500 cardiac patients who have had thoracic epidural analgesia. As far as we are aware he has not published any data regarding these patients. This is not the group that we were addressing and they will have different levels of post operative monitoring and therapy to standard laparotomy patients. Without knowing Dr Scott’s definitions, therapy and completeness of the data set, it is impossible to draw any conclusions on the safety of epidurals from his data. The review quoted earlier found an odds ratio of 13.5 for hypotension with epidural analgesia compared to opioid techniques [1]. We would therefore say there is quite a high level of concern. Thirdly we reiterate our point made in the editorial about the MASTER study. We did not say it was a perfect study. We said that it was the most credible study in this area that has been performed. It demonstrates a number of important points but most significantly, how difficult it is to provide adequate epidural analgesia in these patients. Regarding the significant reduction in pulmonary morbidity and pain, we commented in our editorial that there was a statistically significant reduction in pain scores, but that in both groups the pain scores were low. We still feel that a reduction in pain score of 1 cm on a visual analogue score was not clinically significant. Our comment on the MASTER study being a victim of its own success refers to the fact that it is very difficult to prove benefit in terms of pain scores if your background pain score is so low. Failure rates for post-operative epidurals are high. The failure rate in the MASTER study was 42.5%. This is in the context of a study with enthusiasts involved. It is difficult to see that it will be any less in the UK. The study that you quoted suggesting a 20% failure rate in UK hospitals is not reflective of normal UK practice [4]. This survey was performed when patients with epidural analgesia were routinely admitted to High Dependency Unit for post operative care. This, as you pointed out, is no longer the case. The authors also only looked at epidural analgesia for 48 h which we consider to be inadequate. We therefore stand by our figures of 50% of epidurals failing and possibly even higher. We do however agree with Dr Scott that if you are going to provide an epidural service you must have the ability to adequately assess the effect of your epidural analgesia, strive for total dynamic analgesia and be able to rapidly resite or adjust the epidural. This is both costly and time consuming to provide this service on a 24 h basis. Considering both the decrease in the numbers and experience of junior trainees, it is likely that this role is going to fall to consultants. We are not sure that the cost of providing this service is justified.

More supportive midwives mean no more epidurals

If you read all the research on what lowers epidural rates you could be forgiven for concluding the obvious: if you want to reduce epidural rates, birth where there is no epidural service, because the studies of home birth and birth centres show these women have far fewer epidurals than a comparative group who birth in consultant units (Walsh, 2007). Of course they have some, because a small number are transferred to hospital for complications of labour.