Evidence-Based Medicine: Are Epidurals Safe?

The next underlying assumption about epidural use is that it is safe, and judging by some women’s sentiments, free of consequences.  Let’s explore what our sources have to say.

Assumption #2: Epidurals are safe.

First, what does “safe” mean?  This is a very subjective term, meaning different things to different people.  To some women, “safe” would mean completely free from consequence.  To others, simply safer than the other available options.  Lastly, it could mean that the benefits outweigh the cost. So according to each standard, how do epidurals stand up?

Free From Consequence?

Last week, we learned that epidurals can interfere with the natural hormones of labor, therefore impeding its progress.  So what is the risk to a laboring woman if her labor is slowed?  In simple terms, a “cascade” of interventions could ensue.

Epidurals are renowned for slowing down labor, which could mean your labor might be augmented with something like Pitocin (artificial oxytocin).  Augmentation carries it’s own risks, which we will discuss in later segments.  According to Marsden Wagner (former director of Women & Children’s Health at the World Health Organization),  longer second (pushing) stage of labor means a woman has a four times higher risk of a forceps or vacuum assisted delivery, and at least a two times greater risk of a C-Section.  This is partially because the epidural block effects the mechanisms that rotate the baby into the proper position for delivery.

Additional risks to the mother include:

  • Drop in Blood Pressure (both mother and baby)
  • Itching
  • Higher risk of Infection
  • Fever (15-20%) — this could lead to some invasive diagnostic tests of both the mother and baby
  • Temporary (1 in 500) or even Permanent Paralysis (1 in 500,000)
  • Urinary Retention (inability to urinate) (15-35%) — could require a catheter
  • Severe Back Pain from Birth (30-40%) up to a Year (20%)
  • Spinal Headache (2%)
  • Death (1 in 5,000)

According to Wagner, approximately 23% of women will experience some complication associated with their epidural.  That’s nearly 1 out of 4 women!  And while many women may be willing to put themselves at risk for the good of their baby, very few are willing to put their baby at risk for their own personal comfort.

Risks to the baby include:

  • slowed fetal heart rate (75%), a symptom of fetal distress
  • poor neurological function at 1 month
  • increased risk of breathing difficulties
  • increased risk of breastfeeding difficulties

Even if this is only a partial list, clearly epidurals are not free from all risk, just like any other choice you make.  So, the next question becomes: Is it worth it?  (the risk, that is…)

Is an epidural safer than the alternative?

So, if an epidural provides any benefit to the mother and baby over drug-free birth, it could be considered “safer” than the alternative.

There are in fact, some situations where an epidural is beneficial to the woman — for example if she has had a long or difficult labor, it may allow the mother to rest so she has the energy to push.  Recent studies suggest that receiving an epidural during labor may even help preserve a woman’s pelvic floor muscles (you know, the ones that keep you from peeing yourself).  Other women claim that their freedom from pain made their experience more enjoyable or less traumatic, so there may be a perceived psychological benefit as well.

But, it could still be argued, since all of the aforementioned risks of getting an epidural are not present when having a drug-free birth, that an epidural, while it may provide psychological benefit, does put you at a marginally higher risk of complications.  Therefore, if your definition of “safe” is that it’s safer than the alternative, an epidural is not “safe.”

So, is an epidural safer than other pain management strategies?

Hospitals, in almost every arena, are renown for turning to medicine to solve every condition.  Labor and birth are no different.  Men and women become doctors and nurses, at least in part, because they have faith in the way medicine and surgery work.  They have faith in technology.  It logically follows that medical solutions are in the forefront of their minds when presented with a problem.  Sometimes, however, there are non-medical or non-surgical methods that provide the same benefits to the patient, but with fewer side effects.

Women who choose drug-free birth aren’t just martyrs, masochists, or thrill seekers.  It’s not that they enjoy pain, regardless of what other people might assume.  When they go into labor, they have a plan for reducing pain just like every other laboring woman — they’ve just taken the epidural off the table as an option.  So what kinds of methods do they use?

  • Hot water — baths, showers, birth tubs
  • Movement — walking, dancing, yoga balls
  • TENS (trans-cutaneous electronic nerve stimulation)
  • Hypnosis
  • Acupuncture
  • Continuous one-on-one attendance

All of these methods have been proven to be effective pain management, with no side effects to mother or baby.  In fact, freedom of movement is one of the oldest methods to manage labor pain, and has been demonstrated throughout history to not only relieve pain but to also properly position the baby for birth.  Many women may feel the urge to get up and move if allowed to labor naturally.

Finally —

Is it worth it to take a risk on the epidural in order to avoid the pain?

The only person who can answer this question is the woman herself.  As the evidence suggests, one out of four women will experience some sort of complication with her epidural.  But that means that 3 out of 4 women don’t.  Some women might consider that pretty good odds.  Perhaps the biggest threat is not the side effects of the epidural, but the so called “cascade of interventions” that could ensue, leading to a loss of control over the birth experience.  Then, it’s not only the side effects of the epidural she needs to think about, but the possible augmentation drugs, the forceps, the vacuum, or even the c-section.  And when you consider that there are other, risk free options available, the pharmacological option may seem a little bit less appealing.  1 out of 4 may sound like “good” odds, but 0 out of 4 is even better, no?

Another issue to consider with epidurals is what to do if you are one of the unfortunate few whose epidural wears off.  I’ve come across a few testimonials where a woman went into labor intending an epidural, and the medicine wore off right before she was pushing. I can only imagine how caught off-guard and unprepared for the pain she must have been, and how scary that would be.  It got me to thinking that, if I were a woman going into labor with an epidural, it might be to my benefit to research some “back-up” strategies…you know, just in case.

Since many women experience complications with their epidurals, it would be to the benefit of the hospital and its patients to educate women on natural pain strategies, and to implement them more frequently, rather than jumping right to an epidural.  Like I said above, I highly doubt woman would knowingly put herself, and especially her baby, at risk.  I’m sure many women would be interested to at least try more drug-free options, and then if those are ineffective, the epidural is still available.  Or, if she is in the unfortunate position of having a negative reaction to the epidural, she could feel more prepared to handle her labor pains.

At this point, many women aren’t even made aware they have other options, and that is a failure of the system.  All the more reason to educate yourselves, ladies.  After all, you’re more motivated to do what’s best for you and your baby more than anyone else.

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Build-A-Birth: Are Epidurals a Necessity?

What better place to start our investigations than one of the most common birth practices in US hospitals — the epidural.

Many women today plan for their birth to take place in a hospital, and of those women, most of them plan to receive an epidural for management of pain.  It’s kind of the assumption that a birthing woman will want relief from pain, and that a pharmacological method is the best kind of pain management.  But is this true?  Let’s see what the evidence suggests.  We’ll start with one very fundamental assumption.

Assumption #1: Pain Management is a “necessity” in labor and birth.

I don’t know how many times I’ve heard women say, regarding labor and birth, “why should I suffer if there’s a way to avoid it?”  The assumption is that if it’s available, any woman (in her right mind) would accept pharmacological relief for labor pain.  Since epidurals are available in most every developed country in the world, if this assumption were correct, it would logically follow that those other countries have a similar attitude toward pain management in labor.  So do they?

According to Marsden Wagner’s Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First, a woman’s culture strongly influences her attitude toward pain, both in what kind of pain she expects and how much she feels is tolerable.  In countries such as the Netherlands and Japan, women accept labor pain rather than view it as something to be numbed, and the rate of epidural use in both countries is much lower than in the US.  So why do American women get epidurals so frequently?  According to Wagner, the way a woman views pain during labor and birth are strongly shaped by how her obstetrician views pain.  He states:

“The two great evils in a doctor’s world are pain and death, and they see it as their job to fight them at all costs.  The physiological fact that pain is an essential component of a normal labor, that it is necessary for the release of hormones that control the progress of labor, is either not understood by most American obstetricians or simply ignored.”

So, part of the American pregnant woman’s mindset is influenced by how doctors, specifically obstetricians, view the role of pain in labor and birth.  But surely doctors aren’t 100% to blame.  Think of all the birth stories you’ve ever heard.  How many of them emphasized the pain of birth, or the fear?  If you’re anything like me, a large portion probably did.  So, the attitudes of other women also play a part in our perception of labor pain.  And what about the media?  If I based my perception of birth on “A Baby Story” alone, I would probably think that birth was always chaotic, scary, and horrendously painful.  And it’s not just reality TV — depictions of labor and birth in dramas and sitcoms are also pretty one-sided.  Shows like this litter the airwaves, and it would be silly to think that we are beyond their influence.

It’s been thoroughly established that birth hurts.  Aside from the fortunate few who experience “orgasmic birth,” most women experience some amount of pain when giving birth.  But, unlike most pain we experience in our lives, the pain of birth does not indicate injury.  It is “pain with a purpose.”  To embrace that idea has the power to increase a woman’s confidence while at the same time reducing her anxiety and fear, which in turn can reduce the amount of pain she experiences.  This is demonstrated by the testimonies of women who have had drug-free births, especially those who have chosen to give birth at home, away from even the possibility of pharmacological pain management.

I think the evidence for this assumption suggests that epidurals are not so much a necessity as they are a luxury.  A shift in a woman’s perspective can strongly influence her birth experience, as is shown in other countries where epidurals are available but less commonly used than in the United States.

“We have a secret in our culture,

and it’s not that birth is painful;

it’s that women are strong.”

— Laura Stavoe Harm