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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.

 

 

 

 

 

Discussion

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

  1. People used to ask me about the risks of an (abdominal) operation. I replied that nothing was risk-free; and ask them what the most dangerous part of having an operation was. My answer was that it was the car journey to and from hospital. Not as factual as your answer, but it usually worked.

    As far as ‘natural’ birth and epidurals; is this something biblical, a penalty imposed in the expulsion from the Garden of Eden? Men had to toil in the fields, and women endure the pain of labour. I don’t know the answer.

    Posted by korhomme | May 14, 2014, 10:02 am
  2. You quoted the figure for labor length for multiparous women. For nulliparous, it’s closer to an hour on average. http://www.ncbi.nlm.nih.gov/pubmed/24770287

    Posted by J Zangvil | May 14, 2014, 12:13 pm
  3. Thank you — as a long time L&D nurse, I have really felt badly for women who ‘have’ to ‘go natural’….and even more so for the women with significant others who insist that the women MUST go natural. (I had two ‘support people’ who left when the woman asked for an epidural….they didn’t want any part of the ‘unnatural’ process. Really sad.

    Posted by Melissa Barthold | May 14, 2014, 12:47 pm
  4. As a doula, most of my clients are attempting labor without an epidural, because those women are most likely to seek a doula. They have various reasons for choosing this (never had one say it was because they were required to have pain in labor by their religion). I’m happy to support them, but I stay and support them if they change their minds and request the epidural in labor. I also take clients who are planning to have an epidural. Thank you for pointing out that good labor support matters for all women, no matter what interventions they’re having. In a perfect world hospitals would provide one on one nursing care to women in labor, or provide doulas for every patient.

    Posted by Jennifer | May 14, 2014, 1:18 pm
  5. I didn’t see a few complications I had mentioned, although I had a spinal not an epidural. I had a csection for breech and one long term problem has been an intermittent burning sensation in my lower back that started immediately after I was in recovery. I did not have back pain during pregnancy. It felt like someone had put hot coals under my skin and the burning sensation would radiate down one side of my butt or the other and occasionally would travel down one of my hips and side of my thigh. My OB referred me to a physical therapist a year later because it was keeping me up a night. After 8 weeks of therapy she felt she could not help me and her opinion was that I had scar tissue where the spinal was inserted and it irritated the nerves. My other complication (short term thank goodness) was getting a UTI from the catheter. That was unpleasant, and a week later at my followup appointment my OB mentioned my hospital labs showed a UTI and I told her I already took care of it since I had extra antibiotics at home from the last time!

    Posted by JS | May 14, 2014, 2:07 pm
    • Multiple studies with over 1 million women tell us epidurals do not cause back pain. Many things lead to back pain including positioning on the table, pregnancy, hormonal changes after delivery, weight fluctuations post partum, lowered pain tolerance due to poor sleep, lack of exercise etc. however, when other factors are controlled obstetrical epidurals are not the cause of chronic LBP

      Posted by Dr. Jen Gunter | May 14, 2014, 3:17 pm
      • As a provider…. I never say never… Study or not. If this was her experience… Who are we to dismiss that?!

        Posted by Amy | July 12, 2014, 9:02 am
  6. Great and really useful post. Are you aware of the current news stories in the UK? It’s been recommended that all low risk women are encouraged give birth away from obstetric units, which means they won’t have access to epidurals. I’ve written a couple of blog posts on this and added a link to this blog for info on the pros and cons of epidurals, so thanks for writing it!
    http://southwarkbelle.blogspot.co.uk/2014/05/a-few-more-notes-on-nice-guidance.html

    Posted by SouthwarkBelle | May 14, 2014, 3:13 pm
  7. Actually there are other circumstances where people choose to decline pain-relief. My husband occasionally avoids it for some dental treatments (makes appointments shorter and allows him to eat soon afterwards).

    I am glad epidurals seem to be becoming less intrusive. The desire to be mobile was my main reason to decline one back in the day.

    Posted by Anat | May 14, 2014, 8:49 pm
  8. I assume there is wide variation in the way people feel and interpret pain and I have never given birth through I have been present at three births. I know many women who have given birth without epidurals. Within my limited experience, neither my wife and mother of three or the other women have experienced any ill effects from birthing without drugs. Now it is okay in my opinion to lay out the facts and let women make their choices but I do not think comparing the pain of birthing to amputating a finger has any place in the argument.

    Posted by Medicalskeptic (@medskep) | May 14, 2014, 9:08 pm
    • Actually it does. In pain medicine we try and rate like kinds of pain. Labor, finger amputation, and chronic regional pain syndrome rank among the most painful. It was valid enough for the NEJM review and for the leading expert in OB anesthesia to use, so it’s a good enough comparison for me.

      As I mentioned, pain experiences vary. But there is a movement to make women feel like they are leas for choosing an epidural. Have an epidural or don’t. Neither is wrong, but make an informed decision not one based on societal pressures.

      Posted by Dr. Jen Gunter | May 14, 2014, 9:12 pm
      • I have given birth naturally and it is a beautiful pain of having your sweet baby! Comparing it to cutting your finger is ridiculous to say the least! Of course docs are not going to like intervention free birth because otherwise they are going to be out of jobs!

        Posted by sonu | September 10, 2015, 10:16 pm
  9. As someone who has birthed both with and without an epidural, I think the reason that people interested in natural birth are “afraid” of epidurals is because many of those people want a less medicalized birth, in general. Birthing in a hospital can be full of rules (don’t get out of bed, NPO, scheduled cervical exams, etc) which feel very restrictive and intrusive to what is an intensely personal experience. An epidural comes along with more monitoring, more tubes and lines, etc, and I think that is what is hardest for some people to tolerate (I’ll include myself in that last bit!). For others, tubes and lines are just fine and well worth the trade off. As you said, the key is to make an informed decision.

    Posted by Meredith | May 15, 2014, 6:40 am
  10. Dr Jen, do you know of a study from a year or two ago (can’t remember which journal – must check) that linked maternal fever due to epidural with poorer neonatal outcomes? (I’m aware that fever due to any cause is a bad thing, but it gets used by people of a certain ideology to bash epidurals and the women who choose them – not ok.)

    The other line I’ve heard trotted out is that epidural use is negatively correlated with breastfeeding (e.g. due to fentanyl). I understand this isn’t borne out in meta-analysis, but there is some work that suggests altered neuro-behavioural status in newborns exposed to fentanyl via maternal use. I am always pleased to debunk myths, especially when they are used to disempower women, but don’t have time to do a lit review on every single one, so am grateful for expert analysis if it’s already done!

    Posted by araikwao | May 26, 2014, 12:04 am
  11. Thanks for your post. I really like your emphasis on knowing the facts and making decisions that aren’t based on fear. Women on either side of the debate can easily make a decision because they are afraid of something. And I like your acknowledgment that women have different opinions on the “ideal birth.” I’ve had two non-epidural deliveries – one in a hospital and one in a birth center. My reasons for going drug and epi-free weren’t based on religion or pressure from anyone else, but rather a belief that my body would work best with fewer interventions. I felt like I could trust it to deliver a baby if I just let it do what it knew how to do. It worked out for me (and I always say that I’ll do a natural birth but you won’t find me running any marathons!), although it’s true that sometimes things don’t always go as they naturally should and then we need interventions.

    One thought I had about comparing natural birth to a finger amputation is that I think so much of our perspective of pain plays a role in how painful something is. Birth is a good thing. It’s a life-giving act, so while it was really, really tough to go through those transition stage contractions, it was nowhere near as awful as tooth pain I had during my sons first year. There was nothing redeeming about enduring dental pain, but I was getting a baby after labor and delivery!😉

    Posted by Amy | October 12, 2014, 5:38 pm
  12. Dr Jen Gunter, I don’t think you are being totally honest here.
    Epidurals don’t cause long term back pain. Errrrr, yes they do. What do you think the main symptom of Arachnoiditis is?
    That’s right, back pain.
    How about a blog which gives 100% honesty and then women can make a fully informed decision.

    Posted by Diana | November 7, 2015, 1:51 pm
    • I suggest reading the post before you just to the comments to spread your personal agenda (whatever that may be).

      I quotes a study of over 1 million women and the incidence of serious neurologic injury. Epidurals with steroids are linked with arachnoiditis, steroids are not given in labor. .

      Posted by Dr. Jen Gunter | November 8, 2015, 6:46 am

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