Disclaimer:  The following article involves topics of a medical nature.  This commentary is not supposed to take the place of advice given by a medical professional (midwife or doctor).  It simply provides research information regarding the use of certain drugs and can only be considered general information, not specific advice for a given person.

Epidural_4Epidural.  That one little word has the power to start wars.  Well, not literally, but if you get women in a room together and get them to start talking about the issue of drugs during delivery, you’re bound to end up with your own small scale war.  On the one hand, there are those who feel that epidurals are bad and shouldn’t be given to laboring women at all, on the other there are those who feel that it’s nobody else’s business what they do during their delivery and that if they want pain medication, no one should judge them for it.  Then there’s a third hand which is where I stand.  My view in a nutshell: The development of the epidural was a great scientific discovery that has the power to help women who NEED it in labor.  It has its place in the world of childbearing, but it has also been VASTLY overused and many of those who opt for it have no idea what it is that they’re choosing to do.  Most women are unaware of the risks associated with the epidural and though some would opt for it with that information, some might not and it is our duty to ensure women are aware of risks they are undertaking.

The biggest hurdle to overcome when trying to get people to educate themselves about drugs and childbirth is debunking the myth that whether or not one uses pain medication should be no one’s business but their own.  The main argument is that their decision doesn’t affect anyone else so why should the rest of us care?  Unfortunately for them, there is a couple of glaring fallacies to this argument.  First and foremost, it does affect someone else – your baby.  It continues to amaze me how some women consistently forget that there’s this tiny human who is completely dependent upon us to consider its needs (or even those that realized it throughout pregnancy seem to forget it during the birthing process); and because they forget, the needs of this tiny human are often ignored.  Second, even if it did only affect you, if it can hurt you, then we as a society have the moral obligation to make you aware of it so you can make an informed decision.

But what could be so wrong with epidurals?  I mean, they make giving birth painless and easy, right?  Yes and no.  While an epidural may take away the pain for mom, it can (and regularly does) make labor more difficult resulting in more interventions than a drug-free birth.  There is ample evidence that women who receive an epidural are much more likely to require the use of oxytocin/pitocin[1][2][3][4] (note: pitocin is the manufactured form of oxytocin, the natural drug that occurs in labor and helps keep contractions going) and because of that intervention, these women are also at a higher risk of requiring an emergency c-section[5].

There seem to be a couple contributing factors to this cascading effect of interventions:

The first factor is that once you get an epidural, you’re bed-bound.  No moving, walking, etc. for fear that you screw up that spinal and really hurt yourself.  And as any midwife will tell you, movement is key to getting baby out – gravity is your best friend during delivery.  So when you force a woman to stop moving, you slow things down labor-wise.  Second, epidurals (given when not needed ) weaken your contractions and, as I’m sure you’re aware, you need contractions to continue or, once again, you end up with even bigger problems.  So if labor slows for either of these reasons, you need to make it faster, which is why you add in the oxytocin/pitocin (though I’ve heard of doctors starting with the pitocin just to speed things up—heaven forbid they miss a golf game—and the intense contractions require the epidural to slow it down again and kill the pain).  Of course, the use of pitocin then results in even stronger contractions which can be too much for baby, meaning you end up with baby in distress and the need for an emergency c-section.  Or if the pitocin doesn’t speed things up enough, you could end up with the emergency c-section for failure to progress.  These three interventions are much more intertwined than many people realize.

Perhaps, though, you’re lucky enough to just have the epidural and avoid the pitocin or c-section.  That means you’re in the clear, right?  Wrong.  You also get to worry about infection.  The use of epidurals is also linked with moms getting an intrapartum fever and therefore needing antibiotics during delivery.  The use of antibiotics during delivery is linked to higher rates of sepsis in newborns, requiring antibiotic treatment at birth[6].  Intrapartum fever has also been related to various other adverse effects in newborns, including seizures[7].  So even if you manage to avoid other maternal interventions, you run the risk of causing more harm to your newborn.

Still think the epidural is all fun and games?  Hopefully not, but there’s one more thing to consider: The reason most women get an epidural is to kill the pain; however, have you actually thought about why there’s pain during childbirth?  If there were no reason for pain in childbirth, there wouldn’t be any, so obviously it’s there for a reason.  And while we may never know the exact reason (after all we can’t exactly ask evolution), we can hypothesize based on neonatal outcomes.  One of those reasons is hypothesized to be a way to make sure mom stops what she’s doing and goes someplace safe.  But really, there could be a way to do that without pain per se so it’s questionable how helpful the pain is for that aspect of birth.  Another hypothesis, and one really worth thinking about, is that the pain is there to produce endorphins to help the baby through labor as well.  It is believed that babies can’t produce their own endorphins and so require mom’s endorphins to help with the pain (in case you hadn’t considered it, babies draw an even shorter straw than mom does during this whole labor thing), and the use of an epidural, while killing pain for mom, means baby gets no pain relief during labor[8][9].  That is also one possible reason why babies may go into greater distress, leading to the necessity of an emergency c-section, even without that intermediary, pitocin[5].

I did say, though, that epidurals were useful at times and it’s worth reminding people why they were developed.  For starters, they’re fantastic for women who have to have a c-section because it allows them to be awake and meet their baby much sooner than if they had to be given a general anesthetic.  If you ask any mother who’s had a c-section, they can feel much better about it because they get to meet baby so soon thereafter.  For the non-c-sectioners out there, epidurals are there primarily to help with very long or very painful labors (though the two usually go hand-in-hand), as a labor that goes for too long typically involves mom being too tense to relax at all, meaning there’s no room for baby to get in the proper position to come down.  This can lead to distress for baby, who’s trying to get out, and can be incredibly dangerous, risking both mom and baby’s life (which is why the notion that drugs are never good is just as asinine as that that they are harmless).  Women with back labor are particularly prone to extended and hugely painful labors, and can result in women being in labor for days (sometimes up to five days), and if you’d been in labor that long (with each contraction making you feel like someone’s breaking your back because of the back labor), you might need something to help things along as well.  The epidural relaxes mom enough to allow her to “open up” and let the baby down into the birthing canal and continue with a safe labor.  Notably, in these cases the epidural doesn’t actually slow labor – it speeds it up.  That is one sign that something is doing the job it’s supposed to—it helps the process along instead of slowing it.  (We only consider cancer treatments effective because they slow down the spread the cancer; if they sped it up, no one would take them, so why is birth any different?)

It’s time to make sure women are informed about the interventions in birth.  So that women can take more responsibility for their birthing process, to make sure they know what they’re doing and what’s happening to them at each stage.  It’s also time to start thinking of mom and baby as a unit again.  Throughout history, mom and baby have been seen as one—co-dependent and in sync—yet in Western cultures we’ve lost this sense of connectedness.  Perhaps that’s why it’s so easy for doctors and mothers alike to avoid thinking about the side effects of many interventions.  Not everyone will have or even opt for a drug-free labour, but women should at least be given the knowledge of what is happening and what risks are associated with it so they can make informed decisions.

[Note: Some have suggested the research is out of date.  However, new research supports exactly what was written herein.  For more recent studies, please see the following:

Anim-Somuah, M., Smyth, R.M.D., Howell, C.J., 2005. Epidural versus non-epidural  or no analgesia in labor.  Cochrane Database Syst Rev Issue 4, Art No.: CD000332.

Eriksen LM, Nohr EA, Kjaergaard H.  Mode of delivery after epidural analgesia in a cohort of low-risk nulliparas.  Birth 2011; 38:317-26.

Greenwell, E.A., Wyshak, G., Ringer, S.A., Johnson, L.C., Rivkin, M.J., Lieberman, E., 2012.  Intrapartum temperature elevation, epidural use, and adverse outcome in term infants.  Pediatrics 129, e447-e545.

Jonas, W., Johansson, L.M., Nissen, E., Ejdebäck, M., Ransjö-Arvidson, A.B., Uvnäs-Moberg, K., 2009.  Effects of intrapartum oxytocin administration and epidural analgesia on the concentration of plasma oxytocin and prolactin, in response to suckling during the second day postpartum.  Breastfeed Med 4, 71-82. ]

[1] Mayberry LJ, Clemmens D, & De A. Epidural analgesia side effects, co-interventions, and care of women during childbirth: A systematic review.  American Journal of Obstetrics and Gynecology 2002; 186: s81-s93.

[2] Newton ER, Schroeder BC, Knape KG, & Bennet BL. Epidural analgesia and uterine function. Obstetrics and Gynecology 1995; 85: 749-755.

[3]Ramin SM, Gambling DR, Lucas MJ et al. Randomized trial of epidural versus intravenous analgesia during labor. Obstetrics & Gynecology 1995; 86: 783-789.

[4] Howell CJ. Epidural vs non-epidural analgesia in labour. [Revised 6 May 1994] In: Keirse MJNG, Renfrew MJ, Neilson JP, Crowther C. (eds) Pregnancy and Childbirth Module. In: The Cochrane Pregnancy and Childbirth Database. (database on disc and CD-ROM ) The Cochrane Collaboration; Issue 2, Oxford: Update Software 1995 (Available from BMJ publishing group, London).

[5] Morton SC, Williams MS, Keeler EB, Gambone JC, & Kahn KL. Effect of epidural analgesia for labor on the cesarean delivery rate. Obstetrics & Gynecology 1994; 83: 1045-1052.

[6] Lieberman E, Lang JM, Frigoletto Jr F, Richardson DK, Ringer SA, & Cohen A. Epidural analgesia, intrapartum fever, and neonatal sepsis evaluation. Pediatrics 1997; 99: 415-419.

[7] Lieberman E, Lang J, Richardson DK, Frigoletto FD, Heffner LJ, & Cohen A. Intrapartum maternal fever and neonatal outcome. Pediatrics 2000; 105: 8-13.

[8] http://www.road-to-health.com/64/What_are_Endorphins_.html

[9] http://www.mothersofchange.com/2010/12/are-epidurals-good-for-baby.html