To the Editor

We read with interest, and much dismay, the letter by Dr. Thomas Parker, Jr., regarding labor epidurals in the summer 2005 issue of the APSF Newsletter. Dr. Parker raises some issues that are important and of very real concern to the specialty of anesthesiology. Daytime fatigue and patient-safety concerns owing to night-time work is an obvious and important problem. Provision of comprehensive, 24-hour-per-day anesthetic services in small, rural hospitals is a particular challenge. Limited anesthetic manpower and resources are a source of stress for many practitioners in a variety of settings, both large and small. Appropriate reimbursement for our services is an essential matter of fairness and important to all practitioners.

However, Dr. Parker’s letter was a virtual diatribe against labor epidurals, and more specifically, against the women requesting them. We feel this is misdirected and inappropriate. Dr. Parker refers to women requesting pain relief with labor epidurals as “incessant,” “entitled,” “demanding,” and “privileged,” and to labor epidurals themselves as “non-essential.” Labor pain is one of the most severe pains a woman will ever experience in her lifetime, and relief of this pain is no less important than the surgical anesthesia we provide in the operating room. The provision of obstetric analgesia or anesthesia, either at night or during daylight hours, is one of the most important services that we as anesthesiologists can provide. The women who receive these services are no more or less deserving of pain relief than any other patient in the surgical suite.

What, according to Dr. Parker, renders epidural analgesia in labor a “privilege”? What other services provided by Dr. Parker are considered “privileges,” and who among his patients are “entitled” to receive these services? What is an “incessant demand”? Is the sound of a woman in excruciating pain, pleading for relief, an “incessant demand”? Does the “request” for pain relief become a “demand” when made by a patient without private health insurance? Is labor pain somehow more amenable and appropriate to relieve by regional analgesia at 2 o’clock in the afternoon than at 2 o’clock in the morning? When does a group of patients experiencing severe pain become “overly demanding”? Perhaps when they cannot pay for the services that would provide relief?

The American Society of Anesthesiologists and the American College of Obstetricians and Gynecologists have issued a joint statement that, “In the absence of a medical contraindication, maternal request is sufficient medical indication for pain relief during labor. Pain management should be provided whenever medically indicated.”1 While this document goes on to note, “that of the various pharmacologic methods used for pain relief during labor and delivery, regional analgesia techniques—epidural, spinal, and combined spinal epidural—are the most flexible, effective, and least depressing to the central nervous system, allowing for an alert, participating mother and an alert neonate,” there is no requirement to use regional analgesia. Individual hospitals and anesthesia groups must determine what they can practically and safely provide. This might include single shot-spinal opioids with additional IV opioids as needed, as some smaller centers do, or simply IV opioids if regional analgesia is not feasible. We would further note that this document takes a strong stance on appropriate reimbursement.

Dr. Parker does raise issues of serious concern. These issues deserve ongoing, careful consideration and discussion among the leadership of our professional societies. However, it is not in keeping with the spirit of professionalism that we expect from our anesthesia colleagues to belittle, insult, and disparage women in labor for their entirely appropriate requests for pain relief. These issues need to be faced by our obstetric colleagues as well as hospital administrators, in consultation with the anesthesiologist. Together, we can find solutions and provide adequate pain relief for women in labor, and insure safe, healthy deliveries for the children in our respective communities.

William Camann, MD
Boston, MA

Samuel Hughes, MD
San Francisco, CA

David Birnbach, MD
Miami, FL

---

Reference

1. ACOG Committee Opinion, # 231,” Pain Relief During Labor,” February 2000. This opinion replaces # 118, January 1993. (It is a joint statement from the ACOG Committee on Obstetric Practice and the ASA Committee on Obstetric Anesthesia.)

Editor’s Note: The APSF Newsletter wishes to thank Drs. Camann, Hughes, and Birnbach for their thoughtful input on this important issue.