Why is the “natural” birth movement so afraid of epidurals?

To put this post in perspective the pain of childbirth is said to be equivalent of amputating a finger.

The joint statement of the American Congress of OB/GYN and The American Society of Anesthesiologists sums pain control during labor and delivery quite nicely, “There is no other circumstance where it is considered acceptable for an individual to experience untreated severe pain, amenable to safe intervention, while under a physician’s care. In the absence of medical contraindication, maternal request is a sufficient medical indication for pain relief during labor.”

So then why are so many people opposed to epidurals?

Let’s start with the facts. Everything here is from well-done studies and Cochrane reviews (hence the facts reference).

• Epidurals provide excellent pain relief. For labor and delivery they are superior and safer than any medication that can be given as a shot, by intravenous, or inhaled.
• Untreated pain can have significant consequences beyond the agony of the pain itself. Untreated severe pain in labor is linked with postpartum depression and post traumatic stress disorder.
• Epidurals do not increase the risk of a c-section.
• Epidurals do not impact APGAR scores or effect the neonatal outcome.
• Epidurals can slightly increase the need to have oxytocin (a medication to increase the strength of  contractions). A meta-analysis indicates the chance that a women might need oxytocin increases by about 19%. However, when this is needed and done right it is A) safe and B) does not increase the risk of a c-section.
• Epidurals do lengthen the 2nd stage of labor by an average of 15-30 minutes (the time between being fully dilated and having the baby).
• Epidurals are associated with a 42% increased risk of needing a vacuum or a forceps delivery. This may be because the numbing impacts the descent of the baby or how well a woman can feel to push. However, if the 2nd stage of labor is taking too long or pushing isn’t going well the epidural can always be turned back. The baseline risk of an assisted vaginal delivery in the United States is 5% (this includes all deliveries, epidural and unmedicated, and is very regional and operator dependent). So MOST women with an epidural will not need an operative vaginal delivery.

Other facts:

• Modern epidurals strive to just block the pain nerves and not the nerves that control movement. This allows the best experience and is least likely to impact the second stage of labor.
• With an epidural a catheter to drain the bladder is needed. A mom won’t be able to tell when she has to empty her bladder.
• While the epidural is being placed and in the immediate period afterwards it is necessary to be hooked up to a fetal heart rate monitor for continuous monitoring.

What are the serious risks? Every medication and intervention has them. Including Tylenol and water births.

• 10-20% of women can have some transient abnormalities in the fetal heart rate. This is due to the rapid pain relief that dramatically drops epinephrine (adrenaline) levels. This can be managed with IV medication.
• 80% of women will have a drop in blood pressure due to a variety of factors. Giving intravenous fluids before can prevent this from happening or being of any concern if it does. Occasionally some IV medication (phenylephrine or ephedrine) is needed to correct this. When managed appropriately this has no consequence.

What about more serious complications? There are fears of being paralyzed or having severe life-long problems. A review that looked at adverse effects from over 1.37 million women who received an epidural in labor found the following:

• There is no increased risk of back problems or chronic back pain after an epidural. Pregnant women have back pain, if your pain persists after delivery it was pregnancy related not epidural related.
• The risk of headache after an epidural is 0.7%. Half of these women, of 0.035% of women who get an epidural will need an intervention to treat the headache. (The headache is due to a small hole leaking spinal fluid out, it produces the same headaches as a very severe hangover. This is treated by taking some on your own blood and injecting it in the epidural space and the blood clots sealing the leak. The procedure is called a blood patch. A blood patch sadly does not work for a hangover).

What about really severe complications?

• 1 in 168,000 women will get bleeding around the spine called an epidural hematoma. This is potentially serious.
• 1 in 145,000 women will get an abscess around the spine, also potentially serious
• The risk of a persistent nervous system injury after an epidural in labor is 1 case per 240,000 women (in bold because it’s the biggie most people worry about).
• Bupivacaine, an anesthetic favored in epidurals because it lasts a long time and produces less of a motor block, has potentially fatal complications if it gets into the blood stream. This only happens when there is a medical error of some kind. There is a report of at least one women dying in labor because the bupivacaine meant for her epidural was injected into her intravenous instead. Medical errors can happen with any drug, but hospitals are supposed to follow the 5 rights of medication administration every time to prevent them. If your nurse isn’t, speak up. My 10 year-old double checks his thyroid medication bottle every day before he takes it. Checking your medications should be a life skill.

Just to put the incidence of these serious complications in perspective the risk of a car crash during the first month of the second trimester (while the pregnant woman is driving) is 7.66 events per 1000 pregnant women annually. The risk of a car crash in the 1st month of pregnancy is 4.33 events for 1000 women annually and in the last month of the 3rd trimester it is 2.35 events per 1000 women annually. You are far more likely to crash your car while driving during pregnancy than you are to have a serious epidural complication (by a couple of orders of magnitude).

One very important point to make is that an epidural is not an excuse for a pregnant woman to be without a support person. A support person at the bedside throughout the process improves outcomes and satisfaction. Some studies that look at epidurals don’t address the presence or absence of a support person and this is an important cofactor for C-section rates and operative vaginal deliveries.

I have said it before, there is no prize for pain. However, nothing is ever risk free. Medical errors can happen in the hospital, the epidural could be too dense and you might not be able to move or push, an obstetrician might be trigger happy with c-sections, a lay birth attendant could have you drink too much water in labor at home and you could get water intoxication and have a seizure (seen it happen several times), or a baby could need advanced resuscitation at birth that is not available if you deliver at home.

If labor is not very painful then pharmaceutical relief many not make sense. I have seen women wander into L & D who aren’t even sure they are in labor only to find that they are 8 cm. However, fear about epidurals just doesn’t pan out. Any person offering birth assistance, OB/GYN or midwife, should not talk up or talk down epidurals. If a woman desires to labor without pain relief that is her choice. Some women might be coping just fine without help and others may want to know if they can do it, after all that is why some people run marathons (although at least with a marathon the physical activity improves health, a painful labour does not). However, it is important not to decide against an epidural because of misperceptions about safety or impact on fetal health. If the risk of 4 in a million of a serious complication is too much then you shouldn’t choose an epidural. If a 19% increase in the need for oxytocin is not acceptable to you then you shouldn’t have an epidural.

Everyone has a different pain tolerance. Different people have different ideas about their ideal birth experience. Everyone has a different risk-benefit ratio.

Epidurals have risks, but it is important to put those risks in perspective to make an educated choice. Driving a car has risks. Pregnancy has risks.

Regardless, health care providers who speak ill of epidurals are uninformed and I have to ask what they are really afraid of? A unmedicated delivery is not better in any medical sense it’s simply a choice. To make an informed choice you need facts not fear.