To Epidural or Not to Epidural

Posted on June 11, 2009. Filed under: Epidural, Pregnancy | Tags: , , , , , , |

That is the question that many moms automatically say yes to, no other questions asked. Now, you may think that because I am a doula that I am anti-epidural, pro natural birth only. That is true and not true all at the same time. I am pro natural birth but do realize there are some times when the epidural is more beneficial to the mother than the risks it creates for both mom and baby. I have not had a client get an epidural yet but I would totally support her if she did. Even if she were a planned epidural. I believe all laboring women need support regardless of how they labor. But that’s not really what this post is about. I just wanted to get all that out of the way first so that no one thinks that I am judging. I am not judging and I will try to be as factual as possible. Personally, I am anti-epidural for myself. For everyone else, I say do what you need to do, just make sure you have all the information you need to make the best decision possible. That’s what I am attempting here.

So, why is it that so many women say they want the epidural before they ever even have their first contraction? My bet is fear. We fear birth. Our culture fears birth. We are taught that child birth will be the most excruciating pain we will ever experience. That may be true but it doesn’t mean we can’t handle it. We can SO handle it. We were made to handle it. Here’s a really nice video made by someone researching fear in childbirth…

There are just things that we need to be able to handle child birth that are often times denied to laboring women.

What do laboring women need?

Anyone who has ever had a baby in a hospital knows that some of those things are very hard to come by. So instead, we end up being afraid and in more pain that would be otherwise. For every positive birth experience, we hear 10 horrifying ones. No wonder we run straight to epidurals! But what do we know about epidurals? How much do we understand? Do they really make birth better? The video said that people do not report a higher satisfaction with their birth because they got one. I have a client who had one her first birth and didn’t have one the second time and she was way more satisfied the second time. It’s been six weeks and she’s STILL glowing about her natural birth and how much easier recovery was. Why is this?

SO what exactly is an epidural? Here is the Wiki definition. Here is a video showing how they are administered…

How an Epidural is Administered

What kind of drugs are in an epidural?

A epidural typically has a combination of local anesthetics and opioids. This combination works better than either type of drug used alone. Common local anesthetics include lidocaine, bupivacaine, ropivacaine, and chloroprocaine. Common opioids include morphine, fentanyl, sufentanil, and pethidine (known as meperidine in the U.S.).

What does an epidural do to the baby? According to the American Pregnancy Association:
How can an epidural affect my baby? As stated above, research on the effects of epidurals on newborn health is somewhat ambiguous and many factors may be contributing to newborn health at the time of birth. How much of an effect these medications will have is difficult to judge and could vary based on dosage, how long labor continues and individual babies. Dosages and medications vary, so concrete information from research is lacking. Studies reveal that some babies may initially have trouble “latching on” among other difficulties with breastfeeding. While in-utero, they may become lethargic and have trouble getting into position for delivery. These medications have been known to cause respiratory depression, and decreased fetal heart rate in newborns. Though the medication may not harm the baby, the baby may experience subtle effects like those mentioned above.

That answer is kind of unclear so I looked around for some more answers. This doctor from New Zealand says:

There is a noticeable lack of research and information about the effects of epidurals on babies. Drugs used in epidurals can reach levels at least as high as those in the mother25, and because of the baby’s immature liver, these drugs take a long time- sometimes days- to be cleared from the baby’s body26. Although findings are not consistent, possible problems, such as rapid breathing in the first few hours27 and vulnerability to low blood sugar28 suggest that these drugs have measurable effects on the newborn baby.

Several studies have found subtle but definite changes in the behavior of newborn babies after epidural36 37 38 with one study showing that behavioral abnormalities persisted for at least six weeks39. Other studies have shown that, after an epidural, mothers spent less time with their newborn babies40, and described their babies at one month as more difficult to care for41.

While an epidural is certainly the most effective form of pain relief available, it is worth considering that ultimate satisfaction with the experience of giving birth may not be related to lack of pain. In fact, a UK survey which asked about satisfaction a year after the birth found that despite having the lowest self-rating for pain in labor (29 points out of 100), women who had given birth with an epidural were the most likely to be dissatisfied with their experience a year later42.
(please go here for the references).

What are the risks to the mom?

Here is a link to Ronnie Falcao’s website, She has TONS of information on all sorts of topics posted by midwives all over the country. I chose this page to discuss epidural risk to moms because this link has many midwives weighing in on it rather than just one source. Here are what some of them had to say…

The incidence of chronic back pain (lasting weeks to months) is reported at 10-15%.
Episodes of hypotension are quite frequent in my experience, despite IV fluid loading prior to the procedure. These frequently cause fetal bradycardias and all the resulting interventions, chaos, and fear.
Late decelerations (usually with good variability and referred to as “reflex lates”) are a common sequelae of epidurals. They are not threatening in and of themselves, but they create a cascade of intervention.
Fever is not uncommon (about 20-25%, I believe) and can cause many interventions for mom and baby.
Spinal headaches are unusual in skilled hands, but I’ve seen them.
Vacuum and forceps delivery are significantly increased, as is cesarean section if the epidural is given before 4-5 cm.

Here is what the American Pregnancy Association says of maternal risks of epidural use…

* Epidurals may cause your blood pressure to suddenly drop. For this reason your blood pressure will be routinely checked to make sure there is adequate blood flow to your baby. If this happens you may need to be treated with IV fluids, medications, and oxygen
* You may experience a severe headache caused by leakage of spinal fluid. Less than 1% of women experience this side effect from epidural use. If symptoms persist, a special procedure called a “blood patch”, an injection of your blood into the epidural space, can be done to relieve the headache
* After your epidural is placed, you will need to alternate from lying on one side to the other in bed and have continuous monitoring for changes in fetal heart rate. Lying in one position can sometimes cause labor to slow down or stop
* You may experience the following side effects: shivering, ringing of the ears, backache, soreness where the needle is inserted, nausea, or difficulty urinating
* You may find that your epidural makes pushing more difficult and additional interventions such as Pitocin, forceps, vacuum extraction or cesarean may become necessary
* For a few hours after birth the lower half of your body may feel numb which will require you to walk with assistance
* In rare instances, permanent nerve damage may result in the area where the catheter was inserted.
* Though research is somewhat ambiguous, most studies suggest some babies will have trouble “latching on” which can lead to breastfeeding difficulties. Other studies suggest that the baby may experience respiratory depression, fetal malpositioning; and an increase in fetal heart rate variability, which may increase the need for forceps, vacuum, cesarean deliveries and episiotomies.

Epidural use is also associated with positioning problems during labor. Please see my post on Optimal Fetal Positioning for more details.

So there are some risks to both baby and mom. What are the benefits?

The first one I can think of is pain relief. The APA lists their benefits as:
* Allows you to rest if your labor is prolonged
* Relieving the discomfort of childbirth can help some woman have a more positive birth experience
* Most of the time an epidural will allow you to remain alert and be an active participant in your birth
* If you deliver by cesarean, an epidural anesthesia will allow you to stay awake and also provide effective pain relief during recovery
* When other types of coping mechanisms are not helping any longer, an epidural may be what you need to move through exhaustion, irritability, and fatigue. An epidural may allow you to rest, relax, get focused and give you the strength to move forward as an active participant in your birth experience.
* The use of epidural anesthesia during childbirth is continually being perfected and much of its success depends on the care in which it is administered.

To be honest, I think there are some crappy benefits on that list. Why are we talking c section alertness if we are talking about an epidural being used in a vaginal delivery? And “The use of epidural anesthesia during childbirth is continually being perfected and much of its success depends on the care in which it is administered.” is not a benefit of an epidural, that is a justification for screw ups.

Let’s be honest though, there are occasionally moms who really do benefit from them. If a mom is hysterical and tense and not coping at all and stalled at 5cm, she may need an epidural to relax enough to dilate. I have never had that happen with a client but have had other doulas tell me stories of it. I am not versed on the medical reasons to have an epidural but I have heard of moms being given them because their blood pressure was dangerously high and the epidural would bring it down.

I know, childbirth is HARD. It can be incredibly difficult for some women while other women do it like they do it every day. My husband’s great grandmother had 14 home births in rural Alabama during the first half of the 1900’s. They are still alive today but one, by the way. It can be painful. Extremely painful for some people but then there are those who have almost pain free labors. The thing about labor pain is that it has a purpose. As humans we are conditioned to respond to pain with fear for our own safety. Labor pain, unlike other pain, is actually doing something, it has a purpose. If we are supported in a way that allows us and reminds us of this and that our body is kindly giving us a break in between those contractions, we can take them one at a time and do it! For some of us, labor last days even. It’s usually not hard work for all of those days though. It’s not something we can’t handle.

Getting an epidural is completely a personal choice. I truly believe that we all have the ability to birth without one if we are provided with everything we need to do it. In fact, I have never met a woman yet that I thought “now SHE will totally need an epidural, she can’t do this.” If we have loving support and encouragement and all of the other needs I listed earlier, we CAN birth our babies. We have to learn to trust birth rather than fear it. We have to learn that it is a process and that interfering with the process causes more harm than good. We have to learn to prepare our bodies and our minds for delivery. We have to learn our options. I hope that in this post I have shed some light on the risks of epidural use. I hope that I can inspire some of you to go from here and learn more.

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