Natural vs. Epidural

The Babble Staff

For some mothers the choice is simple: they don't want to be in pain, so they want an epidural. Others don't mind the pain so much as the loss of feeling and control in the lower half of their body that comes from epidural anesthesia, so they opt for natural childbirth. Many women start out with every intention of having a drug-free birth but find that after twenty hours of labor, breathing and thinking happy thoughts no longer cuts it. Doctors will often recommend an epidural if they think labor is being slowed down by the mother's fatigue. Dr. Marjorie Greenfield says women may feel more in control when not in intense pain. On the other hand, not having an epidural means you will be able to walk around, change positions on your own and push more effectively. But new studies show an epidural doesn't increase the chance that vacuum, forceps, or C-sections will be needed during delivery, as has been reported. It really is your call.

You can influence pain at three sites: where it's produced in the first place, at the gate in the spinal cord, and in the brain where the pain is perceived. In working out your own techniques for pain management, you will want to employ pain-relief measures that can control pain at all three of these sites.

To do this, you can practice relaxation techniques to keep your muscles from getting tired and tense. And you can use efficient positions for labors that keep your muscles working in the way they were designed to. Next, you can close the gate in the spinal cord so the cars can't get through. A pleasant touch stimulus, such as massage, sends positive impulses that can block the transmission of pain impulses through the spinal cord. You can also cause gridlock at the gate by sending through a lot of competing vehicles, such as impulses from music, specific mental imagery, or counterpressure.

Finally, you can fill up the receptor sites in the brain so that the pain-cars have no place to park. Blocking access to this third pain-perception site is how pain-relieving drugs work. You can achieve the same effect naturally by manufacturing your body's own painkillers, endorphins.

Take responsibility for your birth decisions. While a painless childbirth is as rare as a sleep-through-the-night newborn, most pain in childbirth is under your influence — if you are ready for it.

Be aware of the options available for medical pain relief, such as drugs and epidural anesthesia.

Complete pain-relief without risk is a promise no doctor can deliver. While today's analgesics and anesthetics are better and safer than ever, there is no such thing as a perfect pain-reliever — one that works, yet is perfectly safe for mother and baby. By understanding what obstetrical drugs are available, what benefits and risks they carry, and how to use them wisely, you will best be able to decide which, if any of them, you want to use.

If only there were a perfect analgesic (meaning painkiller) that would act on only the pain pathways in mother and didn't cross over the placenta to baby. Unfortunately, there is no such panacea. When narcotics relieve mother's body of pain, they also affect baby. An additional concern about narcotics is their effect on the mind, impairing the ability to focus. When combined with natural pain relievers, however, properly used medical pain relievers can get a laboring woman back on track by providing temporary relief, which allows her to rest and recharge. Here is what every mother-to-be should know about choosing and using narcotic pain relievers.

The epidural has made most other methods of pain relief obsolete — and has even done away with the belief that you must experience pain to birth a baby. Yet before you grab for this magic medicine, inform yourself about its benefits and risks.

This is the point where most women sing the praises of the epidural, yet this is also the instant at which a woman becomes more of a patient than a participant. Yes, once the pain is relieved you can rest and recoup your energy. But because the lower half of your body can't move, you will need assistance changing positions. Since the sensation to empty your bladder is impaired, a nurse will insert a urinary catheter to take away urine. Because of the possibility of the epidural lowering your blood pressure, the nurse will monitor your blood pressure every two to five minute until it is stable, and then every fifteen minutes. To keep the pain relief even on both sides of your body, the nurse will turn you from side to side. To be sure baby is handling the epidural well, you will be hooked up to an electronic fetal monitor. You will also notice that the doctor or nurse periodically rubs the skin of your abdomen, checking to be sure the drug is giving you sufficient pain relief, but not ascending high enough to interfere with your breathing. Now comes the juggling act of getting you just enough anesthetic to give you pain relief and help you manage your labor, but not so much that it interferes with your labor.

An epidural generally takes away or at least diminishes the pain of contractions. When labor gets very intense in the active phase, and especially in transition, women with epidural anesthesia seem more relaxed and more "themselves."

If feeling in control is important to you, you may well want an epidural. The emotional experience of un-medicated labor and childbirth usually feels anything but controlled.

Since pushing may be less effective with epidural, you may push longer and may be more likely to end up with an operative vaginal delivery by vacuum or forceps.

Your experience can be more self-directed and less medical if you avoid epidural. Epidural requires an IV, electronic fetal monitoring and usually bedrest. Without epidural, if all is going well, you should be able to move around freely, go in the shower or tub, and you may be less likely to get pitocin, vacuum, forceps, and some other medical procedures. It is as nature intended .

Regardless of your preferences, it is a good idea to keep an open mind and prepare for what comes.

Your practitioner may get the sense that your anxiety or fatigue is playing a role in labor's poor progress. He or she might then recommend an epidural as a treatment to try to get your labor moving. An open mind will help you to reassess the pros and cons of the options, and cope with the unexpected.

Epidural Anesthesia and Childbirth: The Choice is Yours!

An epidural is a method of controlling pain during childbirth. A needle is first inserted into the epidural space that surrounds the spinal cord in the lower back. Then a small tube, or "catheter," is threaded through the needle into the space and the needle is removed. The catheter is securely taped to the back, and remains there until after the baby is born. Medication is given through the catheter to block the feeling of pain from the lower body. Even with the epidural in place, the mother-to-be should feel the pressure of contractions and have the urge to push when the time comes.

Common Questions About Epidurals

There is some discomfort when the skin in the lower back is numbed with medicine. After that, the woman only feels pressure as the tube, or catheter, is placed.

The epidural is usually placed when the cervix is dilated to 4 to 5 centimeters.

A 1998 study showed that women who used epidurals were in labor about 1½ hours longer than women who used IV pain medication. Also, women were able to push the baby out faster when they did not have an epidural.

Opinions vary on whether epidurals lead to Cesarean deliveries. Some people believe that because epidurals prolong labor, they can lead to fetal distress. However, most women who use epidurals are able to deliver vaginally.

Benefits of Epidural Anesthesia Allows mothers to rest if the labor is prolonged Enables some women to cope with the discomfort of childbirth so they can have a more positive birth experience Allows mothers who deliver by C-section to stay awake, and provides effective pain relief during recovery Many mothers have used epidurals during childbirth, so its use has been well studied Relieves pain during forceps delivery, especially when the baby must be turned According to studies, babies born to mothers who used epidurals do not have a higher risk of health problems long term

Disadvantages of Epidural Use Epidurals often cause a sudden drop in the mother's blood pressure, so it must be checked frequently to ensure adequate blood flow to the baby. If the mother's blood pressure drops too low, she may be treated with IV fluids, medications, and oxygen. About 1% of women who use epidurals experience a severe headache caused by leakage of spinal fluid. If the headache does not resolve, the leakage can be fixed by a special procedure. Some people experience side effects such as shivering, ringing of the ears, backache, soreness where the needle was inserted, nausea, or difficulty urinating. Epidural use may make pushing more difficult. This can increase the length of time for labor and delivery and may lead to the use of forceps to help the baby through the birth canal. Women who use epidurals must stay in bed on their side, and have continuous monitoring for changes in fetal heart rate. Because the lower half of the body is numbed, the woman is usually not able to walk without assistance for a few hours after her baby is born. In extremely rare instances, there have been cases of permanent nerve damage in the mother where the catheter was placed.

Talk to Your Doctor or Midwife There are cases when epidurals should not be used for childbirth. If you feel you would like to use an epidural during your birth, or have more questions about epidurals, it is important for you to talk with your doctor or midwife. The information in this pamphlet is for educational purposes only, and is not intended to replace the advice of a trained health care professional.

Because epidural pain medication doesn't go directly into your bloodstream, your baby is unlikely to be affected. (Research data aren't yet clear enough to say that there are no effects.) By comparison, when medication is given through a vein ( intravenous, or IV) or by injection into a muscle (intramuscular), it travels to your baby across the placenta after an hour or so. If your baby is born before the medication wears off, he or she may suffer side effects such as breathing difficulty and grogginess (which are reversed at birth with another medication).

A combination spinal-epidural anesthesia is gaining more use for labor and delivery. Before the epidural line is installed, medication is injected into the spinal fluid around the spinal cord. This spinal injection acts more quickly than the epidural will. Then the epidural line is placed and used for ongoing anesthesia needs.

What are the benefits of epidural pain relief?

What are the drawbacks and risks of epidural pain relief?

With an epidural, you may not be free to leave your bed to walk or use the bathroom. Talk to your health professional about: Having medication light enough that you can walk or at least stand. Walking and changing positions helps you feel more comfortable during labor. Whether the required fetal heart monitoring and IV line can be adjusted to allow walking. Epidural anesthesia using standard medication doses increases your risk of: Having a prolonged labor. The average epidural labor takes an extra hour to deliver the baby. ² (Some studies suggest that epidural labors are no longer than average labors when medication is not given until the cervix is at least 4 cm dilated. ²) Having a drop in blood pressure (hypotension), which can lower your baby's heart rate. This is why you receive fluids through an intravenous (IV) line beforehand and why you're encouraged to lie on your side, which improves blood flow. Being unable to feel your contractions and to push. This increases your risk of needing an assisted (forceps or vacuum) delivery and possibly your chance of needing a cesarean section you wouldn't otherwise have needed. ³ Having your baby move into the wrong position (malposition) because of slack pelvic muscles and a slack uterus. This increases your risk of needing an assisted (forceps or vacuum) delivery. Some experts question whether malposition may happen first, causing pain that leads a woman to ask for an epidural. ² Talk to your health professional about his or her experience with this problem. Having a seizure related to the medication. This is very rare. After childbirth with an epidural, you may have: Back soreness at the catheter site during recovery. This is uncommon. Some women fear that an epidural causes chronic back pain--studies have not shown a connection between new back pain and epidural use. ² Severe, prolonged headache after delivery, when the spinal cord sheath has accidentally been punctured during the procedure. A puncture occurs in about 3% of women receiving an epidural. About 70% of these women develop the headache after childbirth. The puncture is repaired by an anesthesiologist, using another injection in the puncture area. This usually relieves the headache.

Spinal-epidural anesthesia carries the same types of risks as an epidural alone.

The women who got epidurals early in labor were no more likely to have cesareans. They weren't any more likely to need instruments for a vaginal delivery, either. Here's something else interesting: for women who had vaginal deliveries, the time from their first dose of pain medication to the birth was shorter if that first dose was an epidural. A lot shorter — the median time was 398 minutes for an epidural and 479 minutes if the first dose was the systemic pain relief. Women who had epidurals were also in less pain and were less likely to throw up than women who had the systemic pain relief.

What the study means to you: Just like that, the argument for holding off on the epidural until later in labor has a major hole poked in it. It's amazing what a little scientific experimentation will do. The fact remains that people have observed in the past that women who had epidurals early were more likely to have cesarean sections, but the researchers have a plausible explanation: Maybe women who ask for an early epidural are asking because they're in more pain and are already at a higher risk of cesarean sections.

Caveats: There weren't enough women in the study to detect a small increase in the rate of cesarean sections, but it could be argued that a small difference isn't particularly important. Also, the women in this study were having their first babies and had spontaneous labor or spontaneous rupture of the membranes; the same may not be true of women who are on their second pregnancy or who have had labor induced.

Find out more: The American College of Obstetricians and Gynecologists is of the opinion that if a woman in labor wants pain relief, you should give her pain relief.

Read the article: Wong, C.A. et al. "The Risk of Cesarean Delivery With Neuraxial Analgesia Given Early Versus Late in Labor." New England Journal of Medicine. Feb. 17, 2005, Vol. 352, No. 7, pp. 655-665.