| |
November 1998
Volume 62 |
Number 11
|
| |
|
| In the Spotlight:
Epidural Analgesia for Labor
- A Necessity or a Luxury? |
David J. Birnbach, M.D.,
President
Society for Obstetric Anesthesia and Perinatology
On June 16, 1998, an article titled "Childbirth Anesthesia Refusals
Spur Probe" appeared in the Los Angeles Times. (The text
of the article can be obtained on the Internet at <http://www.latimes.com/>.)
This article described the alleged denial of epidural analgesia
to a patient with Medi-Cal insurance at Northridge Hospital in
Los Angeles and has produced an avalanche of letters to ASA, the
Society for Obstetric Anesthesia and Perinatology (SOAP) and the
California Society of Anesthesiologists. Because there are so
many strongly held opinions regarding this subject, I have been
asked, as President of SOAP, to discuss this case and the issues
that have arisen from it.
There is little debate that the incident at Northridge
Hospital, if it occurred as reported, was counter to the guidelines
of the American Society of Anesthesiologists, since that particular
patient might have been denied an epidural block due to her insurance
status and her inability to come up immediately with sufficient
cash while in labor. The ASA "Guidelines for the Ethical Practice
of Anesthesiology" clearly state, "Anesthesiologists share with
all physicians the responsibility to provide care for patients
irrespective of their ability to pay for their care." As I have
previously stated, we do not have all of the details about that
specific California case and, therefore, we should not rush to
judgment about that specific event. Although I made that comment
to the reporters, it apparently was not important enough for inclusion
in the newspaper articles!
This case, however, brings up numerous issues of considerable
importance, which I would like to discuss. I have taken these
questions (in bold) and statements from the letters which have
been sent to SOAP and will attempt to address the key issues.
Is analgesia for labor an "elective extravagance"
or is it a patient's right to receive pain relief during labor?
Although a few continue to debate this question, it
has been addressed many times, and the consensus of opinion
is that any patient who desires analgesia for childbirth should
receive it. An anesthesiologist asked, "If a woman wants breast
implants or a rhinoplasty for cosmetic correction and is on
welfare, would it also be unethical and reprehensible to charge
her?" Labor is not elective, it is extremely painful to most
women, and the relief of labor pain should not be compared with
a request for elective cosmetic surgery. ASA President William
D. Owens, M.D., has stated that "pain during childbirth is no
different than severe pain suffered by a person after surgery
or a person who has been shot or in an accident." In addition,
a joint statement by ASA and the American College of Obstetricians
and Gynecologists (ACOG) in effect since 1992 states, "Labor
results in severe pain for many women. There is no other circumstance
where it is considered acceptable for a person to experience
severe pain, amenable to safe intervention, while under a physician's
care."1 Finally, ASA and ACOG
have helped to clear this issue by declaring that a mother's
request for pain relief is sufficient justification for her
receiving it.2
"Women have been having babies for centuries without medication,
and they won't die if I don't give them an epidural. An epidural
is not a medical necessity. Why do you think that everyone deserves
an epidural?"
The pursuit of effective labor pain relief has persisted
from the first report of childbirth, and there is abundant documentation
that this pursuit of pain-free labor has occupied a place of
prominence in almost every culture. Haggard, in a book titled
Devils, Drugs and Doctors, eloquently suggested that
"the position of woman in any civilization is an index of the
advancement of that civilization; the position of woman is gauged
best by the care given her at the birth of her child. Accordingly,
the advances and regression of civilization are nowhere seen
more clearly than in the story of childbirth." Although it is
true that patients don't die without labor analgesia, too often
they feel like dying during labor!
Can every laboring patient demand and expect to receive
an epidural in labor?
Obviously not. While maternal request represents sufficient
justification for pain relief, the selected form of analgesia
technique depends on the medical status of the patient and her
fetus, the progress of labor, and the resources of the facility
- including not only those of anesthesiology but also obstetrics
and nursing. While most of us agree that patients in labor should
not be denied pain relief for economic reasons, we should remember
that there are some patients who cannot receive an epidural
(for example, the coagulopathic patient), and there are logistical
circumstances that, despite the best of intentions, can preclude
the administration of an epidural. This is a vast country with
extensive rural areas where medical access may be limited. Even
in urban centers, there can be logistical problems that prohibit
or delay epidural analgesia. For example, when three parturients
in active labor all request an epidural at the same time, can
they all expect an instantaneous response? Of course not. Likewise,
hospitals with small obstetric services often have anesthesiologists
who are also working in the operating room and depending on
the nature of the other case(s) being covered, the anesthesiologist
(or a backup) might be delayed in providing analgesia.
"Is epidural block any better than parenteral opioid?
I may need to give a patient analgesia, but I don't need to give
them an epidural."
Some anesthesiologists who wish to avoid administering
neuraxial blockade on patients for whom the procedure will be
poorly reimbursed have suggested that parenteral opioids are
an excellent alternative for those without adequate insurance.
The evidence clearly suggests the opposite. As stated in the
"Guidelines for Perinatal Care" (American Academy of Pediatrics
and American College of Obstetricians and Gynecologists), "Of
the various pharmacologic methods used for pain relief during
labor and delivery, lumbar epidural block is the most effective
and least physiologically depressant, allowing for an alert,
participating mother." Anyone who has witnessed a parturient
who has received an adequate dose of parenteral opioid to relieve
pain will tell you that the patient still complains during contractions
and is usually sedated to the point of profound somnolence in
between contractions. Several recent studies3,4
have demonstrated that epidural analgesia provides far superior
pain relief as compared to parenteral injections of meperidine,
and epidural analgesia has been shown to be far less depressing
on the homeostasis of both mother and fetus.5
Are epidurals dangerous?
An anesthesiologist recently sent a letter to his local
newspaper suggesting that "epidurals are only one of several
tools available. It is also the most invasive, requiring that
a needle be placed into a patient's spine and medication injected
directly into the central nervous system. Although this procedure
is relatively safe (thanks to the skills and training of anesthesiologists),
there are potential life-threatening risks involved with this
technique." He continues, "When treating labor-induced pain,
I, for one, am reluctant to begin with the most invasive and
potentially the riskiest tool at my disposal in lieu of safer
options." Do any anesthesiologists actually believe that statement?
I think not. The argument that systemic opioids are safer than
neuraxial techniques is deceptive for two reasons. First, epidurals
are not dangerous and are eminently safe when placed by skilled
anesthesiologists. Our patients should not be unnecessarily
scared by reading fiction about the immense risks of epidurals.
Second, it suggests that parenteral opioids are a reasonable
alternative to neuraxial block, when for most patients they
are not.
Do I need to offer the same analgesia service to both
insured and non-insured patients (or as stated in a recent e-mail
sent to SOAP, "poor people can't expect to drive a Rolls Royce
or to eat at a fine French restaurant, so why should they expect
to receive the Cadillac of analgesics for free?")
Although this is far more controversial than the preceding
questions, the answer is clear. If we accept that neuraxial
techniques provide more effective pain relief and are safer
for the fetus, how can we suggest that we use inferior techniques
on patients who have inferior insurance? Adequate pain relief
in labor is not a luxury, and if we continue to suggest that
neuraxial techniques are a purely luxury item, how long do you
think that insurers will continue to reimburse us for these
services?
"There is no law that makes me provide my services for
free to the indigent. If I'm not reimbursed, I won't provide the
service." "Did the anesthesiologist have a moral obligation to
provide a service that was not a medical necessity?" "Her alleged
need does not justify the theft of services."
This is incorrect reasoning, which makes us look very
bad in the eyes of the public and may very well place the anesthesiologist
in jeopardy of violating state and federal laws. Many of these
so-called "uninsured" patients have Medicaid coverage and, therefore,
they are actually insured and, according to the U.S. government,
are entitled to the same treatment as patients with third-party
insurance. Our patients (including even those who are uninsured
or insured by managed care organizations that do not adequately
reimburse anesthesiologists) are not stealing anything from
us, and we should not practice in a way that will allow us to
be accused of extorting money from them.
Obviously, none of us is happy about the present situation,
but while we are lobbying for better reimbursement, we cannot
let our patients (and our reputations as caring physicians)
suffer. Socrates summed it up well by saying, "Divinum est sedare
dolorem" (Divine is the work to subdue pain).
"If public sentiment or state law requires that we 'work
for free,' we will stop doing epidurals on all patients."
Although there are some hospitals (mostly those with
very few deliveries) that do not offer epidurals to any patient,
this policy clearly puts the hospital and obstetricians at a
consumer disadvantage if patients have a choice of hospitals.
However, there are hospitals that, for many different reasons,
do not offer epidurals. This is not the same as denying some
patients epidurals, however. Patients and obstetricians delivering
at hospitals without an epidural service know that epidurals
are not available. There are no surprises and there is no "double
standard."
Can we expect the situation to get any better?
Representatives of ASA, SOAP and many state component
societies are working diligently with third-party payers and
government agencies so that we can restructure our current
system and guarantee a fair reimbursement for the care that
we give our patients - all of our patients. There is presently
a large Medicaid reimbursement disparity between obstetricians
and anesthesiologists, and this inequality has put us at a major
disadvantage. With aggressive lobbying efforts from all members
of ASA and with the help of the media, we need to get the message
to insurers and government agencies that this problem exists
and cannot be ignored.
There is no question that we are being placed in an
untenable situation by being expected to perform epidurals without
fair reimbursement (sometimes without reimbursement at all),
while incurring the same medical liability, but if we are to
succeed, we must fight the reimbursing agencies, not the patients.
It is obscene for anesthesiologists to provide services and
not to be reimbursed, but the fairness that we seek will not
occur overnight and it will not happen if we lose support of
our patients or our obstetric colleagues. If reimbursement for
labor analgesia is unacceptably low, anesthesiologists should
also attempt to negotiate subsidization arrangements with their
individual hospitals. Hospital administrators know that to stay
competitive, their hospital must offer an on-demand epidural
service, and in many cases, Medicaid reimbursement to hospitals
is sufficient to allow the hospitals to partially support anesthesiologists
who would otherwise be providing free care.
In an attempt to disseminate the message that anesthesiologists
do care about their patients but that they have been unjustly
pushed to the point where many feel that they cannot afford
to continue practicing obstetric analgesia, I have appeared
on ABC's Nightline show. The transcript can be found at <http://www.abcnews.com/onair/nightline/transcripts/ntl_980618_trans.html>.
In addition, several SOAP Board members and I have been interviewed
by the Chicago Tribune for an upcoming story that we
have been told will discuss our plight and possible reasons
why third-party payers and government agencies have disregarded
our pleas and ignored the cries of our patients.
History has shown that health care is a consumer-driven
market, and women can have major influences on the practice of
childbirth and on reimbursement for labor and delivery services.
We need to ensure that our patients, both individually and as
members of organized women's groups, fight for us, for what is
fair and for what is right. Some of the letters that were sent
to SOAP and ASA or posted on the Internet place the anesthesiologist
at odds with their patients and, in my opinion, will only do us
harm.
In conclusion, I would like to quote my dear friend and
colleague, Gerard M. Bassell, M.D., who wrote the following eloquent
response in the most recent SOAP newsletter: "We are not simply
technicians, we are skilled, caring physicians who have devoted
our lives to the alleviation of pain during surgery and childbirth.
The worth of our contributions should be recognized. Throughout
all of this, the recipients of our services are our greatest advocates.
We should never turn our back on the woman suffering though a
painful labor to achieve a political or economic end."
References:
- Joint ASA-ACOG Statement, American Society
of Anesthesiologists, Park Ridge, IL: October 21, 1992; amended
October 1997.
- American College of Obstetricians and
Gynecologists: Committee Opinion: Pain Relief During Labor.
Number 118, 1993.
- Sharma SK, Sidawi JE, Ramin SM, et al.
Cesarean Delivery. A randomized trial of epidural versus patient-controlled
meperidine analgesia during labor. Anesthesiology. 1997;
87:487-494.
- Ramin SM, Gambling DR, Lucas MJ, et al. Randomized trial
of epidural versus intravenous analgesia during labor. Obstet
Gynecol. 1995; 86:783-789.
- Morley-Forster PK, Weberpals J. Neonatal
effects of patient-controlled analgesia using fentanyl in labor.
Int J Obstet Anesth. 1998; 7:103-107.
David J. Birnbach, M.D., is Director of
Obstetric Anesthesiology, St. Luke's-Roosevelt Hospital Center,
and Associate Professor, College of Physicians and Surgeons, Columbia
University, New York, New York.
return to top
|