Epidural Epidemic - Drugs in Labor: Are They Really Necessary. . . or Even Safe?

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.

10 Intact Truths You May be Surprised to Hear

*Warning, Satire*

10. Phimosis. Yup! It's REAL. It DOES happen. What exactly IS Phimosis? Well, in laymen's terms, it's when the opening of the prepuce (foreskin) is small, too small, in fact, to roll back over the glans (head) of the penis. OMG! Why would we risk this happening to our boys! Well, firstly, it's VERY rare and highly overdiagnosed. Since the foreskin is different on each person (such as the labia on some women is more extended or even the clitoris) it retracts any time between infancy and adulthood. Big range? Yes, yes it is. Therefore, you cannot properly diagnose someone with phimosis accurately before they are an adult, yet it is done all the time. In some cases, this may cause pain to the individual and when phimosis is truly the issue, it can be fixed, most of the time, without any surgery being required. Steroid creams and manual stretching or stimulation to the foreskin can often "cure" this "problem". In the instance of a stubborn foreskin, one need only see the urologist for a small incision in the opening of the foresking to allow it to stretch enough. Circumcision may never even be required for phimosis, so to do it to avoid the RARE possibility of having phimosis, is just not a valid enough reason.

9. SMEGMA. This word, for some reason, seems to have a lot of people freaked out. It is, in fact, a very REAL thing. Smegma is EVERYWHERE. Here's a surprise: YOU have smegma! All it is, is DISCHARGE. It is lubrication for the head of the penis or, in women, for the vagina. It traps bacteria to keep it OUT of the urethra and help AVOID infection. It is important and serves a purpose. Yes, it has an odor! So do you. If you were to smell yourself after a long day or if you hadn't showered, I can tell you, it's probably not attractive and any man would say he wouldn't venture there! Oh my, how dare he! Well, how dare we say it of him!

8. Retraction. It is true. An ADULT male DOES have to retract his foreskin to clean. I hate to admit it. It must really be tedious to have to retract, rince, and replace, instead of just rinsing. I think it might take a whole 10 seconds instead of five, who has that time these days?

7. Unattractive. An uncircumcised male's penis is unattractive. Yup, it sure as heck is. But wait...I have never seen an ATTRACTIVE penis. I've seen both, been with both. You have the choice of the offensive intact penis, with it's extended foreskin hiding the head except during erection or the circumcised penis, with it's scars and roughened head. Gross. I'll just be a lesbian, all penises are ugly. Oh wait, so are vaginas. Damn, I'm screwed.

6. Different from dad. So true. If your husband is circumcised, not doing so to your son is going to leave him wondering why they are so different. But, with all circucmsions being performed different, healing differently, penises being different sizes, adult men having pubic hair there seems to be a whole list of things that are different between father and son just with their genitals. So, if I have to worry about explaining that, what am I going to do when my son has a different nose, or ears, or chin than my husband? Or why my husband has a hairy chest, or deep voice! Oh my goodness, I am running into all sorts of problems here. But, at least I can try to make their penises look similar. That is a load of my back!

5. STD's. Quite a few different studies support a slight decrease in the transfer of STD's in circumcised partners. Most of these are in regards to men circ'd later in life or done in other countries. Nonetheless, I don't want my boy bringing home the nasties! But wait, can't he still get it? So, it's not a guarantee, right? I mean, the only way to PREVENT getting and transferring STD's is to practice SAFE sex or abstinence. I'm not really sure how the fact that it's decreased is relevent, but I suppose it is a lot easier to have him circumcised at birth and not have to worry about educating him on safe sex practices. Plus, how uncomfortable would THAT conversation be!

4. Culture. I don't think I need to tell anyone that circumcision is a cultural thing. And not just in the US, in other places around the globe. We have one of the highest circumcision rates of developed countries. And, we're America! We know what we're doing...right? I mean, we do have some of the highest HIV/AIDS rates, even though we're making sure to circumcise our boys because as we learned, it prevents that, err...CAN prevent...err, MAY decrease the risk of that. Nonetheless, it's cultural. It's the American way, and of course, America has NEVER been wrong. *cough*Bush*cough*

3. UTI's. This IS true. Circumcised men are less likely to get UTI's! PRAISE BE! However, girls still get far more UTI's, too bad we have to waste money on antibiotics for them. For boys, it's so much easier, since we have circumcision available to fix that! I mean, sure, they can still GET UTI's, and it's rare for a boy to get one anyway, but, like I said, all the money we'll save in copays for visits and prescriptions by just paying one time for circumcision, that is a HUGE load off of my back, especially since I'll need that money to pay for my girls' treatments.

2. Religion. It's obvious that all religions have demands from their higher powers to do or perform certain things. Most require some form of prayer or praise and even different types of sacrifices. For Jews and Muslims, circumcision is one such practice required by God. I mean, yea, there's a group of Jews that oppose circumcision, but they aren't orthodox anyway. And, well, I know that none of us practice EVERYTHING that our faith teaches, but that's why God gave us free will, it makes it easier to pick and choose which parts we follow to suit our needs and which ones we ignore.

1. Choice. Here's the shocker: circumcision is a parent's choice. I'm not arguing with that. How can I? The law SAYS so. If I were to say it wasn't your choice, that'd be like saying blue is REALLY purple. It's simply not true, no matter how many times I say it! Is it the right choice? Should it be a choice? I mean, why not! But, how come I can't circumcise my daughter? Oh, the law says it's not my choice, that's right. But, what about my dog? Oh, you mean it protects him too? I remember when my mom's horse got an infection, and she had to clean out his sheath. Have any of you SEEN a horse penis? Do you KNOW how big those things are? FAR bigger than a man's! Anyway, I remember her saying what a PITA it was to clean that and you know, if only she could have circumcised her horse, she would never have had to deal with that! Instead, she was FORCED to clean him out and give him antibiotics. Damn horse.

You have entered a NO DRAMA zone.

Please, know your rights!

The concepts of informed consent and the right to refuse treatment are supported by constitutional law (the right to privacy and self-determination protected by the First and Fourteenth Amendments); federal law (the Emergency Medical Treatment and Active Labor Act and the Patient Self-Determination Act); international tort law; as well as state laws and stated-mandated medical ethics. They are also covered in the ethical guidelines of the American Medical Association(AMA) and the American College of Obstetricians and Gynecologists (ACOG).

These laws provide all patients, pregnant or not, with certain fundamental rights:

The right to exercise self-determination and autonomy in making all medical decisions, including the decision to refuse treatment.

The right to bodily integrity. Any form of non-consensual touching or treatment that occurs in a medical setting constitutes battery.

The right to be provided with the necessary information on which to base medical decisions, including a diagnosis; recommended treatments and alternatives; the risks, benefits, discomforts and potential disabilities of proposed medical treatments; realistic expectation of outcomes; a second opinion; and any financial or research interests a physician may have in proposing certain treatments.

The right to be informed of any potentially life-threatening consequences of a proposed treatment, even if the likelihood of experiencing such and an outcome is rare.

The right to make medical decisions free from coercion or undue influence from physicians.

The right to have informed medical decisions witnessed, signed, and documented by the attending physician and another adult.

The right to revoke consent to treatment at any time, either verbally or in writing.

Source: Born in the USA by Marsden Wagner