Naila Ramji defends the practice of asking women in labour to undergo an early epidural in the context of the current pandemic.
As a high-risk pregnancy fellow and obstetrician, I have been working to safely and compassionately manage the care of pregnant women during this unprecedented pandemic. Various precautions have been taken to reduce virus transmission. In such circumstances, we must adapt how we manage risk and uncertainty. We must weigh benefits and risks to individuals against those of the larger community, including the health care providers needed to care for the anticipated wave of sick patients.
A community hospital in Ontario was recently criticized in the popular press for requesting that women in labour consider early epidural during the COVID-19 pandemic. That request was erroneously reported by the Ottawa Valley Midwives as being “required”. The idea of requesting women in labour to consider an early epidural falls well within the realm of reasonable precautions that an obstetrical unit or hospital may take to minimize risks and prevent poor outcomes in pregnant women and newborns.
Why obtain an epidural early in the labour process? This recommendation is not based on everything going right in labour, but taking adequate precautions should everything go wrong. Unfortunately, press coverage to date does not adequately explain the basis for some of these concerns. Consequently, individuals may be unable to fully appreciate the negative implications of hospitals not taking certain precautionary measures, whether that means limiting the number of support persons allowed in the birthing room, or potentially transferring patients to a different hospital for safety reasons.
In an obstetrical emergency, every minute of delay can mean the difference between life, severe disability and death, for the mother and/or the fetus. If an emergency Cesarean delivery is needed and the woman does not have an epidural already, she has to be put to sleep with general anesthesia, which requires placing a breathing tube in the patient’s throat. This procedure “aerosolizes” the virus, ratcheting up its mode of transmission from contact and droplets to a more dangerous form, where viral particles hang in the air and can infect anyone in the room. Preventing infection from aerosolized virus requires higher level personal protective equipment (PPE), of which there is a national and global shortage, and ensuring “negative pressure” rooms where this occurs so that opening the door will not send viral particles out to the rest of the hospital. Ideally we want to avoid aerosolization whenever possible during the pandemic.
Another problem with emergency C-section during COVID-19 is expected delays for the proper donning of PPE before surgery. If we further delay by having to place an epidural during the emergency, this can lead to serious adverse outcomes. In smaller communities, where the surgical team is not in the hospital, adding 10-20 minutes to the usual and accepted 20-30 minutes from the decision to proceed with C-section to starting surgery can be detrimental to achieving good outcomes.
Importantly, requesting women in labour to consider early epidural still involves informed consent. Patients would have the opportunity to ask questions and raise their concerns after learning of the benefits, risks, and alternatives from health care providers. Ultimately, patients have the right to refuse.
Informed consent discussions often happen with women in labour – that is when most request an epidural. And for emergency procedures, we have no choice but to obtain verbal consent under less than ideal circumstances. Although decision-making capacity may be limited in labour, with women less likely to recall risks and benefits while experiencing painful contractions, bioethicists agree that it is ethical to provide these women with a requested epidural because the epidural both alleviates their suffering and restores their capacity by treating their pain.
A small community hospital’s obstetrical service requesting women presenting in labour to consider early epidural, in the context of the COVID-19 pandemic, is therefore reasonable. The possibility of requiring transfer to a different centre if the request is refused, on a case-by-case basis, may also be reasonable, when compounded time delays could lead to serious adverse events, including severe disability or death of the fetus. Concerns about patient welfare, safety, and meeting standards of care in various contexts, are already part of transfer considerations. Misinterpreting reasonable precautionary measures as violations of individual patient autonomy serves neither patients, providers, nor hospitals well during a public health crisis.
Naila Ramji is a clinical fellow in Maternal-Fetal Medicine at the University of Ottawa, and a practicing Canadian Ob/Gyn, with an MSc in Bioethics from Columbia University.