Do Epidurals Get A Bad Rap?

Slate ran a piece last week called “The Truth About Epidurals” in which Melinda Wenner Moyer delves into the research on epidurals and concludes that they don’t seem to carry the many risks often attributed to them. I read the piece with great interest as I find that epidurals are largely misunderstood. Thursday in a New York Times blog, KJ Dell’ Antonia asks,”Did you, like Ms. Moyer, feel overwhelmed by the pressures surrounding the question of the epidural, both for and against? Why has such a personal decision become such a polarizing debate?”

I’m a birth educator and I think it’s important not to demonize pain medication in childbirth. There are so many things wrong with maternity care in this country, but the epidural is really not high on the list of problems. I’d rather fight about early early or unnecessary inductions or the fact that too many hospitals offer no pain coping help aside from an epidural.

Moyer’s article does expose some irritating myths about epidurals though I think some of the potential risks are under-stated. And some studies have been flawed.

Moyer refers to one study, for example, which demonstrates that women who get the more modern, lower dose epidural can feel their toes and move during labor, thus enabling gravity-friendly and hip-opening positions, and possibly reducing fetal distress and helping with the pushing phase. This may be true, but as it plays out in hospitals most women who get (even low dose) epidurals are not roaming the halls. For one thing mom has to be continuously monitored; she is attached to not just the epidural but a monitor, an IV and a blood pressure cuff. She’s tethered to several machines. I’ve heard labor and delivery nurses laugh when they hear the words, “walking epidural.”

Moyer points to some large studies from respectable sources like the Cochrane Library, showing that epidurals don’t increase c-section risk. But one quibble: If you look at the Cochrane Review she links to, you’ll see this: “The review identified 38 randomized controlled studies involving 9658 women. All but five studies compared epidural analgesia with opiates.” This means that in the vast majority of the studies used to support the claim that epidurals have no bearing on c-section rates, laboring with an epidural is compared to laboring with an intramuscular shot of narcotics NOT to laboring with no medication at all. This complicates things.

Moyer mentions the risk of a low fever with an epidural. Since it’s not dangerous to the mom or baby, she understandably doesn’t linger on this as a major issue. But as it plays out in hospitals, there are some not-so-fun consequences. The baby of a mom with an epidural-induced fever, though not sick, must be treated as if exposed to infection. Many hospitals will put the baby in the Neonatal Intensive Care Unit (NICU) for 24 hours of observation after birth. Knowing that the risk of fever with an epidural increases when it’s been in place for more than five hours may influence your decision about when to get one.

Having said all that, I think it’s true that epidurals are not at the heart of the soaring c-section rate.  Studies do show that, given in active labor (post 4 cm), epidurals do not raise the c-section risk. And if administered after a very long painful all-nighter labor that stalls, an epidural can reduce the chance of a c-section. It’s all about timing and context.

Epidurals carry fewer risks than any other medicated pain relief we’ve come across (except for laughing gas, which is depressingly scarce in US hospitals). There are risks and side effects you should be aware of–sometimes these risks are overstated but just as often they are not stated at all. (If you really look at what a lot of serious birth activists are in such a huff about it tends not to be pain relief but informed consent.) You get to weigh these risks against the benefits. No one else can do this for you. Unlike Bill Clinton, we don’t “feel your pain.” You feel it, you decide.

As for the reason this conversation becomes so polarized, I don’t know. Help me out.

Is it because it’s easier to fight with each other than against a system that doesn’t always cater to evidence-based practices?

Let’s think about this though. All women want pain relief in childbirth. The women I teach who are giving birth at home go to all kinds of lengths to plan for the pain– hiring a doula, getting a tub to labor in, learning the best positions to take the pressure off, becoming familiar and comfortable with how birth works so that fear doesn’t take over, etc, etc. An epidural is just one way to cope among many. And we all need to cope. Recognizing vulnerability in labor is, to me, a sign of strength and bravery not weakness. And making your own decisions about your own body and your own care is empowering, whatever they are.

Also of note:

Women who get epidurals say they feel more connected to the birth, more present, more aware of what was happening.

Women who don’t get epidurals say they feel more connected to the birth, more present, more aware of what was happening.

Pain relief in childbirth was and is fought for by feminists.

Natural childbirth was and is fought for by feminists.

So, how about we keep the epidural but add more options?

Too many hospitals offer no pain coping help aside from an epidural. Women do not get continuous support in labor unless they bring it themselves. Doctors often show up just for the end of labor. Nurses have largely been replaced by monitors. In NYC there are fewer than a handful of birthing rooms with tubs in them. I think this is appalling as studies have shown women who get into a tub in labor experience the same level of pain relief as from a shot of narcotics, without any risks.

Since we have such an epidural-friendly birth culture, women who want to labor without medication have to make a big stink. Then the women who use epidurals feel attacked. Then the natural birthers say, it’s not about you… Then everyone has to rush to the studies to find some empirical basis for their preferences. But, as Moyer points out in her piece, studies only show so much. Recently we learned that “less than a third of the recommendations from the American College of Obstetricians and Gynecologists (ACOG) are based on gold-standard scientific experiments.”

In a survey conducted for the book I co-wrote on pregnancy and birth, From The Hips,  one woman wrote in, “Why can’t we have the freshly baked bread and the epidural?” I’ve never forgotten that line. It broke right through this notion that each woman must pick a side.

Like the rest of life, a balance of nature and technology tends to make the most sense. We want organic raspberries and an iphone. What I’d like to see is more respect for nature and better, more judicious use of technology. Like, could we please get ambient monitoring in the US? How crazy is it that the entire world is wireless except for the ridiculously outdated fetal monitors in most US hospitals? I could go on…

Also on Babble: 12 things you should know before you get an epidural

photo: Sarah Ridgley/Flickr

Article Posted 5 years Ago

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