To celebrate the upcoming release of our Intervention Pocket Guide, we are going to share with you some of the new research on interventions! Last week I had so much fun on Episode 244 sharing the research on amniotomy (or AROM), assisted vaginal delivery (also known as forceps or vacuum assisted delivery), and internal monitoring. Today I’m going to reveal information from the Pocket Guide on 3 more interventions– Pitocin Augmentation, Regional Analgesia (Epidurals and Spinals), and Cesareans.
Content note: discussion of the benefits and risks of these interventions, including the risk of mortality.
Make sure you’re on the Pocket Guide wait list by going here!
Resources and References
Make sure you’re on the Pocket Guide wait list by going here
· Webinar on the Evidence on Pitocin
· EBB #131 Evidence on Pitocin in the Third Stage of Labor
· EBB #224 Failure to Progress or Failure to Wait webinar (also on YouTube with PowerPoint slides)
· EBB YouTube series on Pain Management https://evidencebasedbirth.com/category-pain-management-series/
· EBB 113 Evidence on VBAC
· EBB 236 Unexpected Cesarean after a normal vaginal birth with Katie Kane
· EBB 226 Emergency Cesarean with Mandy Childs
· EBB 62 Unplanned Cesarean with Michelle Wilson
· EBB 79 From a Cesarean to VBAC with Chanté Perryman
· Breech Series episodes 171 (vaginal breech story with Janae and Andrew Rick), 172 (Breech Vaginal Birth evidence with Dr. Rixa Freeze and Dr. David Hayes), 173 (evidence on ECV for breech)
Hi, everyone. On today’s podcast, we’re going to talk about the evidence on three interventions, Pitocin augmentation, epidurals, and cesareans. Welcome to the Evidence Based Birth® podcast. My name is Rebecca Dekker and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details.
Hi, everyone, and welcome to today’s episode of the Evidence Based Birth® podcast. My name is Dr. Rebecca Dekker, pronouns she/her, and I’ll be your teacher for today’s episode. Today, I’m so excited to bring to you some brand new evidence-based information about three interventions. But before we get started, I want to remind you that our newest project, the Pocket Guide to Interventions, is coming out next week, Monday, November 14 to the wait list and Tuesday, November 15 to the general public. The Pocket Guide to Interventions is about the size of my hand, a little bit smaller. It’s about 44 to 46 pages long, and it’s color printed, laminated, so it’s cleanable, reusable, and it’s on this handy little keyring so you can keep it packed in your birth bag or hanging at the nurse’s station or in your scrub pockets or your purse or your backpack. In this brand new pocket guide, we cover informed consent, medical biases, self-advocacy, and all the research on the different interventions that might be offered during childbirth.
And we talk about the benefits, risks, and alternatives to each intervention. We’re only going to have a limited number of physical copies in stock. So if you want to get your hands on one of these pocket guides, you want to get on the wait list. Just go to evidencebasedbirth.com/pocketguide. That’s all one word, pocketguide, to get the notification when the sale goes live to the wait list. We will also have limited copies available of our other two pocket guides, The pocket Guide to Comfort Measures and The Pocket Guide to Labor Induction, both of which have been sold out for a while now. Again, these will be available next week, November 14 for the wait lists and November 15 to the general public. So to celebrate the upcoming release of this pocket guide, we’re going to share with you some of the new research on interventions that we’ve never published anywhere else that are included in the pocket guide.
Last week I had so much fun on episode 244, sharing the research on amniotomy or artificial rupture of membranes, assisted vaginal delivery, also known as forceps or vacuum-assisted delivery, and internal monitoring. So today I’m going to teach about some information from the pocket guide on three more interventions, Pitocin augmentation, cesareans, and epidurals or regional analgesia. As a content note, we will be talking about the benefits and risks of these interventions, including the rare risk of maternal and fetal or neonatal mortality. There’s so much information in today’s episode that is not published anywhere else by Evidence Based Birth®, and I can’t wait to share our new research with you. Are you ready? Let’s go. So first, let’s start with Pitocin augmentation. So labor augmentation is using synthetic oxytocin and or artificial rupture of membranes, which we covered last week, to increase the frequency or strength of contractions in a labor that was not induced.
So with Pitocin augmentation, a synthetic or factory made form of the hormone oxytocin is given by intravenous line. So the generic name of this drug is oxytocin, which is sometimes confused with our natural own internally made version of oxytocin. They are chemically identical, but there are some differences in how they are enacted in the body. So for the purposes of keeping things clear in this podcast, we will refer to it as synthetic oxytocin or Pitocin when we’re talking about the factory made version that is used in Pitocin augmentation. Another brand name of this medication is Syntocinon. So your own natural oxytocin and synthetic Pitocin are identical in chemical structure, but there are differences in how they act in the body. Your own oxytocin rises in both blood and brain fluid and inside your central nervous system in your brain, it can lower anxiety, pain, and stress.
On the other hand, Pitocin does not cross into the brain because of the blood brain barrier. When synthetic oxytocin or Pitocin is given IV, it can cause more frequent, longer and more painful contractions when it’s given in high doses. Around the world, providers and clinicians seem to be split on whether they prefer giving high doses or low doses of Pitocin. Now, oxytocin in the body, both natural and synthetic, causes the uterus to contract by binding with oxytocin receptors on the cell surfaces of the uterus. When there is a lot of synthetic oxytocin circulating, as you might see with high dose regimens, something called receptor desensitization can occur. It’s also called oxytocin receptor down regulation. This means that the receptors start to become less sensitive to the oxytocin that’s circulating, and contractions may become irregular or non-productive. So you would think like the more oxytocin you give someone synthetically through IV, the more they would contract and they do up until a point when the receptors become so overstimulated that they start to shut down and then your contractions can start to decrease in strength and become more abnormal.
This is less likely to happen in a spontaneous labor where you’re not given Pitocin because oxytocin is released in a natural labor in pulses and then rapidly broken down by an enzyme so that there’s very little oxytocin left in between each pulse. I want to give a shout out to Erin Wilson MPH, one of our research editors at EBB, for helping me write the page on Pitocin augmentation for the pocket guide, and she also helped teach this content in our public webinars this past month. Erin pointed out in her work that there are a lot of variations around the world in how clinicians use Pitocin. I already mentioned that some people use different dosing of Pitocin. Other clinicians will use Pitocin during labor for different reasons, maybe because the labor has slowed down or stalled out, or maybe it’s just that healthcare provider’s standard practice to “actively manage labor” and encourage it with Pitocin rather than letting it unfold on its own.
There’s not a clear consensus in the medical community about when labor should be augmented with Pitocin and what dosing to use or the timing of the dose increases. Like so many clinical practices that we talk about here at Evidence Based Birth®, the idea of Pitocin augmentation can be traced back to one landmark study. In this case, the study was called Active Management of Labour, and it was published by O’Driscoll and colleagues and carried out at the National Maternity Hospital in Dublin, Ireland in 1973. When they did this study, there was no medical rationale for using Pitocin to augment labor. They just wanted to have more efficiency in the hospital and the use of the hospital rooms, and they had a very strict protocol that the doctors and nurses had to follow. The study enrolled 1,000 consecutive patients who were giving birth for the first time at this hospital.
They had to be in labor before they were admitted to the hospital, so none of them were being induced. They all had to have one-to-one continuous nursing support. So each patient had their own nurse, and Pitocin and artificial rupture membranes were used If cervical change was less than one centimeter an hour for two hours straight. This study had a very low cesarean rate of only about 5%. And if you look a little bit more closely at the people included in this study, only about half of the 1,000 patients received Pitocin. The other half were progressing at the desired rate on their own. About half of the patients had zero pain medications at all, and half of them were given opioids for pain management. Only 13 patients out of the entire study of a thousand patients had epidurals. It’s so fascinating to me that we base around the world our use of Pitocin augmentation on this one small study that wasn’t even a randomized control trial.
Some more recent evidence on Pitocin augmentation never compares Pitocin augmentation to no Pitocin augmentation. Instead, it tends to compare high dose Pitocin to low dose Pitocin. One meta-analysis of four randomized control trials found no differences in outcomes between high dose and low dose Pitocin. A more recent 2019 double blind randomized trial between low dose and high dose Pitocin augmentation found that the high dose Pitocin had more side effects and no benefits on the cesarean rate. So sometimes doctors will say, “Well, we use high dose Pitocin because that means you’re less likely to have a cesarean.” But there is no research to back that statement up. In fact, the research we have right now shows that it does not lower the cesarean rate to use high dose Pitocin and it has more side effects. These side effects include hyperstimulation of the uterus and subsequent abnormal fetal heart rate tracings.
We found another study of more than 7,000 births. This one was not randomized, but they were simply documenting the practice in a setting and they found that Pitocin was misused 21% of the time, meaning it was used for Pitocin augmentation when the medication was not needed, when labor was progressing normally and quickly. Despite this lack of evidence, many hospitals around the world used high dose Pitocin to manage labor, both what they consider prolonged labor and even normally progressing labor. So what are the benefits and risks of this regimen? Well, the benefits are that Pitocin, when it’s used for augmentation, can cause stronger contractions when needed. This could be helpful if your labor has stalled or if an epidural has caused a decrease or decline in your contractions. Also, one pro of Pitocin is it can be stopped or paused as needed and it very, very quickly leaves your system.
However, there are four notable risks to Pitocin augmentation. Uterine tachysystole is defined as having more than five contractions in 10 minutes averaged over 30 minutes. This is an abnormal contraction pattern that can lead to fetal distress. Second, there is an increased risk of uterine rupture if you’ve had a prior cesarean. Third, it requires an IV line and continuous fetal monitoring, and often internal monitoring is recommended, which we talked about last week. Fourth, Pitocin is considered a “high alert drug.” This means that if a mistake is made or a drug error, this could lead to a bad outcome. So what are some alternatives to Pitocin augmentation? Well, we talk about this in our Failure to Progress article and podcasts, but there are a lot of options you can use if labor seems to be abnormally long or exhausting and you want to move things along.
These include an epidural for pain or sleep, which we’ll talk about next, addressing fetal positioning, having hands-on support from a doula, using a birth ball or peanut ball, using walking or upright positions, laboring in a tub or a shower, hydrating with fluids, either IV or oral fluids, maintaining your nutrition and energy with food. And for some people, they may choose a cesarean or an assisted vaginal delivery if labor has been abnormally long and exhausting, they’ve tried everything and they’re ready for the baby to be born. Also, there is research that we can increase our natural oxytocin with interventions like nipple stimulation, or you could try using privacy or cuddling with a partner to try and boost your own natural oxytocin. If high dose Pitocin is proposed, one alternative would be low dose Pitocin, which has been shown by research to have fewer side effects. With a low dose Pitocin, it would start at one to two milliunits per minute and be increased by one to two milliunits every 30 to 40 minutes and would rarely go above the dose of 20 milliunits per minute.
So that is a brief overview of the evidence on Pitocin augmentation. If you’re interested in learning more about Pitocin, I recommend you check out our recent webinar which we posted to YouTube. Thank you to Erin Wilson, MPH, and Ihotu Ali, MPH, our research editors who helped put that webinar together. We also have two podcast episodes you might find helpful. Episode 131 on Pitocin in the Third Stage of Labor and episode 224 on Failure to Progress or Failure to Wait.
So now let’s talk about the evidence on regional analgesia. Epidurals, spinals, and combined spinal epidurals are called regional analgesia because they provide pain relief to a region of your body, typically from the abdomen down. An analgesia means pain relief. So regional analgesia means pain relief to a region. An epidural is when a needle is used to guide a catheter into your back. The catheter is placed right below the spinal cord and it takes about 10 to 15 minutes for a pain relief effect to begin.
So a medicine which is typically a combination of a numbing agent plus an opioid can be continuously infused through the epidural catheter, plus extra doses can be given as needed. A spinal block is different because it’s a one time injection into a sac of spinal fluid. With a spinal, they use a smaller needle and a lower dose than what you get with an epidural. You get immediate pain relief with a spinal, but the relief only lasts one to two hours. And then a combined spinal epidural is just like what it says. You get the immediate pain relief of the spinal, but you also get the continuous dosing with an epidural. With a combined spinal epidural, lower doses can be used, and sometimes this is called a walking epidural, but this is a little bit of a misnomer because it doesn’t always mean that you can walk.
So what does the research evidence say on regional analgesia? Where we go into depth on this in our YouTube series on pain management, in particular we have three videos all about the evidence on epidurals. So I’ll link to those in the show notes. But the main evidence that we have is a big Cochrane review where they combined evidence for more than 40 randomized control trials. And when they combine all this data together, they found that epidurals lower pain levels by about two to three points on a zero to 10 scale compared to getting opioids either through an injection or through an IV. And the Cochrane review also found that epidurals do not increase the overall risk of having a cesarean. In general, researchers consider regional analgesia to be the most effective form of pain management for childbirth. So let’s talk about the benefits and the risks.
The benefits of regional analgesia are that it’s highly effective and a lot of people like that allows them to sleep if needed. Say you’ve been having a long exhausting labor or you’re just really tired, the ability to fall asleep and not have pain from the contractions can be a really big benefit. It also can be given as soon as desired and continued throughout labor if you choose the epidural or the combined spinal epidural. Stronger doses can be given if you need a cesarean or you need an assisted vaginal delivery like we talked about in last week’s episode on forceps and vacuum. Also, regional analgesia is considered to be less risky than injectable opioids and serious complications are very rare. In terms of the risks, one of the main risks is a lack of satisfactory pain relief. About one in eight people report unsatisfactory pain relief, and it also usually requires a lot of other interventions.
So in general, you’re going to get a bundle or package of interventions with an epidural, including but not limited to, continuous electronic fetal monitoring, intravenous fluids, a bladder catheter, Pitocin augmentation, mobility restrictions, and continuous oxygen monitoring and frequent blood pressure monitoring. So having regional analgesia does tend to medicalize a birth. There are also risks that are specific to the birthing person and the fetus or newborns. So talk about the birthing person risks first. These have been documented in trials and include a longer pushing phase, something called a motor block, which means it’s more difficult to move your legs. There’s a higher risk of needing forceps or a vacuum, higher risk of having a fever or a drop in your blood pressure. There’s higher rates of cesarean for fetal distress. Some other side effects include itchy skin, feeling nauseous or having urinary retention, which is often why they use a bladder catheter along with the epidural.
About one in a hundred people will have a spinal headache, which is a severe headache. You can also have decreased respiration and drowsiness, skin infection in a sore back where the needle was inserted, and numbness or tingling in your back. In terms of risks to the fetus or newborn, there is a risk if your blood pressure drops that the baby could have low oxygen during labor. There’s also a higher rate of abnormal fetal heart tones, higher rates of babies being born with low Apgar scores, higher rates of babies being born with trouble breathing, poor muscle tone, difficulty with breastfeeding or chest feeding. And all these side effects to the newborn tend to be lower than what you get with opioids, like if you’re just given a shot of opioids. And these side effects are more common with an epidural if you have what we call a high dose epidural where you’re given more than 150 micrograms total of fentanyl over the course of your labor. So similar to Pitocin augmentation, with epidurals, the higher the dose, the higher the risk of side effects.
So what are some alternatives to regional analgesia? Well, you could decline one or you could wait until you need an epidural or want one. You could also elect to have injectable opioids or nitrous oxide or laughing gas. And there are physical comfort measures that don’t involve medication, such as having a doula support, using a birth ball, using mobility or getting in a tub or shower or having massage or counter pressure. Doulas can provide valuable physical and emotional support whether or not you have an epidural. There are also more mind related comfort measures that you can use to reduce your pain perception or the strength of the pain that you’re perceiving. And we cover all of these in our pain management series on YouTube and also in our Pocket Guide to Comfort Measures. In our Pocket guide on Interventions, we have a whole page with tips for epidurals, including what to expect, ways to cope, and what you can do after the epidural is inserted and what you might expect at that point.
I had a lot of fun putting together that page on tips for epidurals. I actually had lunch with our EBB instructors in Oregon, Scarlett Lynsky, Molly Patterson, Marnellie Bishop, and Ali Buchanan, and together they helped me brainstorm all of these tips for people who have epidurals. So far today, we’ve talked about the evidence on Pitocin augmentation and epidurals or regional analgesia. And now I’d like to end with the research evidence on cesareans. A cesarean is defined as a major surgery in which the baby is delivered through an incision in the abdomen and uterus. A cesarean requires an operating room or operating theater, as they call it in some countries, and the relevant staff. Cesareans are also called C-sections, cesarean deliveries, surgical births or belly births. I’d like to note that cesareans can be planned or unplanned, urgent or not urgent, preventable or not preventable, and they’re also life saving and in other cases overused.
And believe me, here at EBB, we’ve talked with people from every single one of those categories. A cesarean includes interventions such as regional analgesia or rarely general anesthesia, a bladder catheter and intravenous fluids and medications. Some hospitals separate the birthing person from the baby immediately after a cesarean. On the other hand, some are now providing family centered care and permitting skin to skin contact in the operating room. The evidence on cesareans is complicated. One of the things that you need to know is that we don’t really have randomized controlled trials on cesareans because who’s going to agree to be in a study where they flip a coin and decide if you’re having a cesarean or a vaginal birth? Exactly. So we don’t have those kinds of studies. Instead, we have observational studies where they look to see what happened in people who have planned cesareans, unplanned cesareans, and vaginal births.
It can be really hard to compare these three groups because the people with planned and unplanned cesareans may have had complications that led to those cesareans. So these three groups are not equal to begin with. Basically what the researchers have found that all three of these categories have both short term and long term benefits and risks. And weighing the benefits and risks to make an informed decision as to whether or not you’re going to have a cesarean often depends on the reason for cesarean. Some cesareans are obviously medically indicated. The benefits clearly outweigh the risks. For example, I had a student in the EBB Childbirth Class who recently required an urgent cesarean for placental abruption where the placenta was tearing away from the uterus. That was definitely a life-threatening situation in which the cesarean was the only way that that baby could be born and that they could both survive.
We also had a recent graduate of the Evidence Based Birth® Childbirth Class talk about having an emergency cesarean in episode 226 due to a life-threatening complication called Bandl’s ring. In those kinds of situations, there’s really no doubt about it. The benefits clearly outweigh the risks, but there’s a lot of other reasons that might fall into a more gray zone where it comes down to a personalized decision as to whether or not you want the cesarean or not or feel that it’s needed or not. In general, when they’re comparing planned cesareans to unplanned cesareans, the unplanned cesareans tend to have higher risks, possibly because of complications that led to the fact that you had to have an unplanned cesarean. So what are the benefits and risks of a cesarean? Well, I pulled up several of these systematic reviews where they were combining evidence from lots of different observational studies.
Again, these were not randomized control trials, but observational studies. And in general, this is what I found. The benefits of cesarean include a lower risk of severe perineal tears, including a lower risk of obstetric anal sphincter injury. Also, there is a lower risk of uterine rupture with a planned repeat cesarean instead of having a VBAC. And we go more into the evidence on VBAC in depth in episode 113 of our podcast. There’s also a lower risk of experiencing postpartum urinary or fecal incontinence or pelvic organ prolapse with a cesarean. In terms of looking at the risks of a cesarean, I want to divide that into mortality risks, short-term risks, and long-term risks. In large population based studies, researchers have found that if someone has no prior history of a cesarean, there is a slight increase in the rare risk of maternal and newborn death with both planned and unplanned cesareans compared to vaginal birth.
The results are slightly different if you have a history of a prior cesarean. In people who already have a scar on their uterus from a prior cesarean, with a future cesarean, there’s a slight increase in the rare risk of maternal death and a slight decrease in the rare risk of newborn death with the repeat cesarean. And again, if you go to episode 113, the evidence on VBAC, we go into a lot more depth about the research evidence on repeat cesareans and VBACs. Looking at the short-term risks of cesarean surgery, the risks include a longer hospital stay, experiencing injury during the surgery, negative reactions to the anesthesia, incision pain or infection, delaying the start of breastfeeding or chest feeding, microbiome changes in you or the baby, newborn breathing problems, and rarely an urgent removal of the uterus called a hysterectomy. Long term risks of cesarean surgery for the baby include asthma.
However, there is conflicting evidence on this, and I found that researchers have not come to a solid conclusion about whether or not cesarean increases the risk of asthma. But in general, there is consensus that cesareans increase the risk of metabolic syndrome. So it goes up to about 1% of babies who are born by cesarean will develop metabolic syndrome. Eczema which is three to 7% is the chance. Respiratory infections which can range to 16 to 18% in babies who were born by cesarean. Ear infection rates are higher in cesarean born babies and gastrointestinal disorders are higher, but they’re still pretty rare at only 0.6%. For the birthing people who have cesareans, there are longer term risks with subsequent pregnancies. You may experience pressure to have another cesarean, and there is a higher risk of fetal loss in future pregnancies, placental accreta, and uterine rupture with the future vaginal birth, which is about 0.5%.
And again, you can learn more about placenta accreta and uterine rupture in episode 113. So what are the alternatives to a cesarean? Well, one of the alternatives is just getting more time in making sure that there’s more patience among providers and staff for a vaginal birth, especially during an induction which could take two to four days at nights. Another alternative to cesarean in specific circumstances, you could have an assisted vaginal delivery, which is a forceps or vacuum assisted delivery, and we covered that in last week’s episode. And then finally, assessing and treating fetal position. For example, if the baby is in a posterior position, or you could talk more about the evidence on how to handle a breach situation. And we have a whole podcast series on breach vaginal birth. Just go to episodes 171, 172, and 173. We recently got some feedback because we do teach the evidence on cesareans inside the evidence space for our Childbirth Class.
Occasionally we get feedback from parents who feel like this information is too much presented in terms of risks, but our team has decided to continue talking about it in this way because it is a major abdominal surgery and there are risks to surgery. The Pocket Guide on Interventions goes into depth. We have another page all about preventing cesareans when they are preventable, and we list evidence based ways to lower your risk of having one, and other cesarean prevention tips. And we also have a page on family centered cesareans, how you can write a birth plan for a cesarean and make a cesarean a better experience. And some options you might want to consider on your cesarean birth plan as well as ways you can cope during the cesarean. So that wraps up the end of this overview of the evidence on Pitocin augmentation and epidurals and cesareans.
There’s more included in the pocket guide that I didn’t get to go over, including self-advocacy tips and scripts for ways you can talk about these things with your care providers and some last resort advocacy methods if you feel like you’re really not being listened to, as well as the evidence on birth plans. So the pocket guide is going to be released next week, and like I said earlier, there are limited copies available of the physical version and we’re also going to be restocking our other pocket guides. So make sure you get on the wait list at evidencebasedbirth.com/pocketguide, and we can’t wait to help people learn even more research evidence on these interventions. Next week we’re going to be talking about debunking infant food reactivity myths with Dr. Trill Paullin, a molecular biologist and founder of Free To Feed. Then November 23, we will be taking a podcast break.
I hope to see you all next week. Thanks, everyone. Bye.
Today’s podcast was brought to you by the signature articles at Evidence Based Birth. Did you know that we have more than 20 peer reviewed articles summarizing the evidence on childbirth topics available for free at evidencebasedbirth.com? It takes six to nine months on average for our research team to write an article from start to finish, and we then make those articles freely available to the public on our blog. Check out our topics ranging from advanced maternal age to circumcision, due dates, big babies, Pitocin, vitamin K, and more. Our mission is to get research evidence on childbirth into the hands of families and communities around the world. Just go to evidencebasedbirth.com, click on blog, and click on the filter to look at just the EBB signature articles.
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