Epidural Epidemic - Drugs in Labor: Are They Really Necessary. . . or Even Safe?By Joanne Dozer and Shannon Baruth
Issue 95, July/August 1999
The use of epidurals is so common today that many perinatal professionals are calling the 1990s the age of the epidural epidemic. Believed by many in the medical profession to be safe and effective, the epidural seems now to be regarded as a veritable panacea for dealing with the pain of childbirth.
It is true that most women experience pain during the course of labor. This pain can be intense and very real, even for those who have prepared for it. But pain is only one of many possible sensations and experiences that characterize the experience of giving birth. Barbara Katz Rothman, a sociologist who studies birth in America, writes that in the medical management of childbirth, the experience of the mother is viewed by physicians as pain: pain experienced and pain to be avoided.1 Having experienced childbirth ourselves, we have great compassion for women in painful labors. However, we also feel a responsibility to mothers and their babies to explore issues concerning the use of epidural anesthesia in labor issues that are seldom discussed prenatally.
Several factors make the use of epidurals potentially hazardous. The Physician’s Desk Reference cautions that local anesthetics - the type used in epidurals - rapidly cross the placenta. When used for epidural blocks, anesthesia can cause varying degrees of maternal, fetal, and neonatal toxicity which can result in the following side effects: hypotension, urinary retention, fecal and urinary incontinence, paralysis of lower extremities, loss of feeling in the limbs, headache, backache, septic meningitis, slowing of labor, increased need for forceps and vacuum deliveries, cranial nerve palsies, allergic reactions, respiratory depression, nausea, vomiting, and seizures.2 In addition, a piece of the catheter that delivers the drug into the duraregion of the back may break off and be left in the woman, a dangerous risk that necessitates surgical removal. One of the most well-known side effects of spinal anesthesia is a spinal headache. Depending on the amount of anesthetic used and how the catheter was placed, the headache can be mild or severe, lasting between one and ten days after the birth. This is not how any of us wants to feel in our first days and hours with our newborn.
Epidurals also have been linked to an overall increase in operative deliveries: cesareans, forceps deliveries, and vacuum extractions. A meta-analysis of the effects of epidural anesthesia on the rate of cesarean deliveries was undertaken by a group of physicians who examined, categorized, and analyzed all available literature. Eight primary studies revealed that the rate of cesarean section was 10 percentage points higher in the women who had received epidural anesthesia. One study actually found that the cesarean rate increased to 50 percent when the epidural was given at 2 cm dilation, 33 percent at 3 cm, and 26 percent at 4 cm.3 What caused this increase? In the first stage of labor, the muscles of the pelvic floor may become slack from the numbing effects of the epidural, causing the baby to change an otherwise ideal position or fail to descend into the pelvic cavity. In the second stage of labor, the anesthetized woman often is unable to push effectively since she cannot feel her muscles. When the baby does not descend properly or is malpositioned, progress can slow or stop, resulting in a longer labor and the increased possibility of a cesarean section, vacuum extraction, or forceps delivery.
In addition, epidurals usually slow contractions, which prompts medical personnel to administer intravenous Pitocin in order to strengthen them and increase their frequency. Even with Pitocin, which carries its own set of risks, an anesthetized labor may remain prolonged, risking a difficult labor with lack of progress. Prolonged labors put both mother and baby at greater risk of infection, necessitating the use of antibiotics. The longer a labor and slower the progress, the more likely it will end in a forceps, vacuum, or cesarean delivery. Since cesarean section is a major surgery, it strongly influences a woman’s recovery and the initiation of breastfeeding. Of course, the rate of postpartum infection is much higher with cesarean births. All vacuum extraction and forceps deliveries increase the risk of morbidity and birth injuries.
Another effect of epidurals during labor is the creation of hypotension in the mother, which can lead to bradycardia (a decrease in the heart rate) in the fetus. All types of anesthesia, including epidurals, can negatively affect the baby’s heart rate, possibly leading to fetal distress and necessitating an operative delivery. The newborn can continue to have breathing difficulties after birth, requiring supplemental oxygen or even resuscitation. While these problems may be resolved immediately following the birth, they often require the mother to be separated from her baby for neonatal nursery observation. This separation delays bonding and initial feeding. In addition, poor muscle tone and increased acidity in the baby’s blood due to bradycardia and oxygen deprivation may affect her ability to suck effectively, hampering initial attempts at early breastfeeding.
A mother’s temperature may become elevated with the use of epidural anesthesia, resulting in the infant being taken to the nursery and given a full work-up for possible infection. This may include extensive blood work and a spinal tap.4, 5
Furthermore, though epidurals usually remove all sensation in the lower body, "windows" can occur which leave the woman experiencing the intensity of her labor (perhaps on one side of her body) but with extremely limited mobility - obviously hindering her ability to cope with her contractions.6 The idea that pain medication can play a role in "natural childbirth" is deceptive, despite the assurance of the authors of What to Expect When You’re Expecting that "...wanting relief from excruciating pain is natural...therefore pain relief medication can play a role in natural childbirth."7 This is rather twisted logic, since the concept of natural childbirth depends on the mother experiencing both mental and physical sensations of labor. The epidural may allow a woman to be awake and aware of what is happening, but she will not be experiencing a natural labor as she will be numb to any physical sensations below the waist. A split between the mind and the body is effectively created with this anesthetic, disengaging her mind from her physical feelings. Could such disconnection be natural childbirth? Robbie Davis-Floyd, an anthropologist who studies birth in America, argues that the woman in labor with an epidural "...is separated as a person as effectively as she can be from the part of her that is giving birth."8 There is an eerie quality to this kind of birth; the mother is robbed of her own connection to her power and life-creative force. She loses the opportunity to experience the inherent wisdom of the body and its ability to birth without interference. Indeed, most women who have felt childbirth agree that it was a deep, enriching, and positive experience.
What alternatives do women have for the relief of pain in labor? Unfortunately, many women enter the birth experience with a strong belief that birth is something horrible and nightmarish. They are already filled with fear, not only for their own and their baby’s safety but also about what they have heard is the unbearable pain of childbirth. Another important fear is that of "losing control" during labor and delivery. A mother often is labeled out of control if she expresses the natural, primal sounds of labor. Technologically oriented medical practitioners who are sure that childbirth is something to be wrestled into submission feel that the sound of a mother wailing in pain is a sign that she is "losing it" and ought to be medicated. In hospitals, mothers are often told by well-meaning nurses to be quiet so as not to disturb the other "patients." But release of sound is a natural way to express and release painful - and intense - sensations. Suppressing a mother’s natural instincts to move around freely and make noise in labor will increase her actual pain. The prepared childbirth movement - in particular the Lamaze technique - has been successful for some women by helping them remain "in control" by training for structured labor breathing. However, some women actually do connect to their body rhythms and natural breathing patterns in labor, and if they are more loyal to themselves than to their training, they may be seen as wild, out-of-control "Lamaze failures." This failure is defined as their inability in labor to be mannerly and controlled. In fact, one of the primary psychological reasons for lack of progress and cesareans is a fearful mother’s unconscious attempts to control the intensity of her labor. Her lack of progress is due to her inability to let go and surrender. Mothers are told they must be in control when actually they need to let go.
So how does a mother let go and find her way through the pain of labor? First, she needs to give birth where she feels safe. For some women this may mean a medicalized hospital birth; others may feel safest at home or in an alternative birthing center. Most women find that they feel safest in the loving hands of a practitioner with whom they have developed a supportive and loving relationship. This person may be a special kind of doctor or it may be a midwife. Midwives specialize in personalized, supportive perinatal care. Support is the best form and prime source of non-pharmacological pain relief. Support can also come from the love and care of a partner. If you are having your baby in a hospital, it may be worthwhile to secure the help of a knowledgeable friend or a doula. Support can be active: massage, breathing together, encouraging words and attentiveness, and reassurance that what it happening is normal and that you are handling it well. Other support can be more passive: a midwife’s calm demeanor, a gentle nurse’s presence, the peaceful attentions of loved ones. A laboring mother needs to feel safe, loved, and accepted. And when she is, whether she screams, hollers, whines, moans, bargains, begs, or just plain doesn’t act "civilized," giving birth vaginally without medication is a triumph in itself.
One of the ways to endure labor is to recognize (ideally, during one’s prenatal education) the connection between fear, tension, and pain - the "fear-tension-pain syndrome." Basically, when a mother feels fear, she will be tense and experience more pain. Relaxation relieves the tension that helps create the sensation of intense pain. The notion of a relaxing labor might seem crazy, but it is possible, and we have seen it many times. Of course, a mother will feel more relaxed and safer in the birth environment of her choice and with her chosen caregivers. Perhaps the more the mother chooses about her birth environment, the more fully she can relax.
Childbirth education classes that focus on birth as natural and normal encourage women to trust the birthing process. Birthing is full of new sensations which can be frightening and difficult to integrate; some women tell us that they felt they might split in two! Understanding the reasons behind the sensations can make them more manageable, since we fear most that which we do not understand. Another key concept in prenatal education is truly believing we can birth our babies, just as women have done for ages. The world was well-populated long before modern obstetrics, and today the lowest maternal and infant mortality and morbidity rates are in the countries where natural, midwife-assisted births are the norm.
Not only can we birth our babies naturally, we can birth in our own style. Birth doesn’t need to be performed in any specific way. It is a woman’s right to create her labor her way, and she needs to be accepted for her way of doing it. She may find help in deep breathing, light breathing, dancing, singing, yelling, screaming, moaning, crying, walking, or bathing. She needs support for whatever works to assist her to birth her baby. Soaking in water can also help tremendously in reducing pain in labor. Prenatal yoga can be extremely helpful since it teaches women to relax by using deep breathing techniques and imagery. Both of these methods help her to connect more profoundly to her body and baby.
No woman should feel like a failure for having used pain relief medication during labor. There is a time and place for it in specific circumstances, and epidurals may be very effective. However, the decision to use an epidural should be an educated one, made only after all other options have been exhausted. Birthing is hard work. It is sweaty, noisy, and emotional, and it always requires our full attention. If we accept this, and stop trying to make birthing "civilized," we can help mothers to endure and cope.
Assisting a woman who is giving birth also is hard work, requiring education, love, and our full attention. Supporting birthing women in this way results in less fear, less pain, and a decrease in the need and desire for epidural anesthesia. The satisfaction of a natural birth - including the sheer endurance of pain and sometimes overwhelming sensations - is accompanied by great joy, even ecstasy. The realization of all these complex emotions is experienced not only by the mother but also by her partner and those who assist, attend, and support her in labor. The sense of joy and accomplishment from a natural birth is the right of every woman - and a wonderful gift to any newborn in those very special, first moments of life.
NOTES
1. Barbara Katz Rothman, In Labor: Women and Power in the Birthplace, (New York: W.W. Norton & Company, 1991), 80
2. Sifton, David W. Ed., The Physician’s Desk Reference (Montvale, NJ: Medical Economics Company, 1996), 2318.
3. Joseph Gambone, D.O., and Katherine Kahn, M.D., "The Effect of Epidural Analgesia for Labor on the Cesarean Delivery Rate," Obstetrics and Gynecology 83, No. 6 (June 1994):1045-1052; Thorp, M.D., et. al., "Epidural Anesthesia and Cesarean Section for Dystocia: Risk Factors in Multiparas," American Journal of Perinatology 8, No. 6: 402-410; Thorp, M.D., et. al., "The Effect of Intrapartum Epidural Analgesia on Nulliparous Labor: A Randomized, Controlled, Prospective Trial," American Journal of Obstetrics and Gynecology 169, No. 4: 851-858.
4. Author’s name, "The Bad News About Epidurals," Time, March 24, 1997, page 40.
5. Fusi, et al., "Maternal Pyrexia Associated with the Use of Epidural Analgesia in Labour," Lancet 8649 (3 June 1989): 1250.
6. B.M. Morgan, S. Rehor, and P.J. Lewis, "Epidural Anesthesia for Uneventful Labor," Anesthesia 35 (1980): 57-60.
7. Arlene Eisenberg, Heidi Murkhoff, and Sandee Hathaway, What to Expect When You’re Expecting (New York: Workman Publishing, 1984), 227.
8 Robbie E. Davis-Floyd, Birth as an American Rite of Passage (Los Angeles: University of California Press, 1992), 115. OTHER REFERENCES
Griffin, Nancy. "The Epidural Express: Real Reasons Not to Jump On Board," Mothering , Spring, 1997.
Mitford, Jessica. The American Way of Birth. Dutton, New York, 1992.
Morton, Sally, Ph.D.; Williams, Mark, M.D.; Keller, Emmett, PhD.; Peaceman, M.D., et. al., "Factors that influence route of delivery - active vs. traditional labor management," American Journal of Obstetrics and Gynecology, Vol. 169, No. 4, 940-944.
Sepkowski, Lester, Ostheimer and Brazelton. "The effects of maternal epidural anesthesia on neonatal behavior during the first month," Development of Medicine and Child Neurology, 1992, 34, 1072-1080. This article was originally edited by Leslie Hauslein. Shannon Baruth is a birth assistant, apprenticing midwife, mother to Cassidy Rose (2 1/2) and Sage (14 months), and partner to Michael. She graduated from Bryn Mawr College in 1997 with a bachelor’s degree in anthropology. She resides in rural Wisconsin. Joann Dozer is a registered nurse and CPM who has been delivering babies at home for more than 20 years. A trained Gestalt therapist, she provides counseling and workshops for women and couples. Joanne is the mother of Scott, born in 1968 in a hospital delivery that included the use of Demerol and spinal anesthesia; Lianna, born in 1973 in the birthing room of an Amish midwife’s home; and Emily, born in 1976 at home with a midwife and doctor.
