epidurals.

Epidurals are extremely popular among birthing women today. In many hospitals in the United States epidurals are used in 80% of all vaginal deliveries (1). Remarkable! Epidural analgesia is offered to all women in labor. An epidural allows the mother to be awake, gives her relief from the pain of labor and can prevent most of her negative or stressful physiological responses to labor pain, so that she can be more relaxed while giving birth. So, what's the problem? The truth is there are plenty of problems associated with the use of epidural analgesia in labor. The saddest part is that the doctors are not telling women what the problems are. First, let's look at how epidurals work. The majority of pain in labor results from uterine contractions and cervical dilatation. Pain during the pushing phase is primarily from the pressure of the baby moving down, involving the perineum and causing intense rectal pressure. Pain relief will be concentrated in these areas. For a woman to receive an epidural, she must have an i.v., continuous electronic monitoring and be confined to bed for the duration of her labor. "Epidural" is actually a generic term that describes any number of medications being administered to the mother. The word "epidural" is used because the anestheologist inserts a needle into the "epidural" space surrounding the mother's spinal column. A catheter is put into place through which the painrelieving medications will pass. The anestheologist will first administer a "testdose" of medication to make sure the catheter is correctly placed. Then the drugs that make up the "epidural" will be administered, usually by a continuous pump mechanism. There are various combinations of local anesthetics or narcotics (or both) used in the epidural mix. The drugs used most frequently are bupivaine, chloroprocaine and lidocaine. The woman will experience numbness from her belly down. Although, sometimes the medication is not evenly dispersed and this can create a "patchy" or lop-sided effect, allowing women to still feel pain in some areas while being numb in other areas. Pain relief is achieved in 85% of women (2) (3). The three components used in the epidural: the needle, the catheter and the local anesthetics, are also the culprits when it comes to maternal complications. Although complications in the mother are rare, at about 1 in every 4,000 epidural placements, they include toxic intravenous injection with convulsions or cardiac arrest; infectious problems, including meningitis or epidural abscess and neurologic complications (4). “Anybody who tells a woman that epidural is safe is lying." Marsden Wagner, M.D. (5) There are hundreds of studies published in medical journals noting the risks of epidural anesthesia to mothers and babies. The research presented here represents a fraction of the information available to physicians and hospitals. Yet, women are constantly reassured by their ob's and anestheologists that epidurals are safe. This is simply not the case. Epidurals pose great risks, but, more importantly, they rob women of their birth experience. Women have a drugged sense of reality when they give birth under the influence of epidural anesthesia. Women deserve more and their babies deserve a drug-free entrance into this world. Contrary to popular belief, there are many dangers involved with the use of epidurals in labor. Epidural use, especially when placed early, is strongly associated with prolonged labor (6). When time in labor was compared, the epidural group had significantly prolonged labor : over six hours compared with over three hours in non-medicated women (7). This lengthening of labor by an average of three hours was observed in both first time mothers and mothers birthing subsequent babies. The time frame from induction to delivery was also found to be longer in the epidrual group. When a woman has an epidural in place, She may have ineffective contractions (8). When nerve endings are blocked by epidural anesthesia, the woman no longer feels the pain of labor. However, by blocking these nerve endings, labor stimulation is also inhibited. An oxytocin infusion (Pitocin) is provided to most women who receive epid als, hoping that this will shorten the length of labor by counteracting the adverse effects of irregular uterine contractions (9). Epidurals decrease uterine performance, even in women who receive oxytocin to stimulate their labors (10). When oxytocin (Pitocin) is used to augment labor, the time in labor is still prolonged with an epidural in place. The amount of Pitocin required to enhance cervical dilatation was higher among women with epidurals. A medication as powerful as Pitocin can not overcome the effects of epidural analgesia. When giving birth to their first babies, the need for augmentation of labor with oxytocin use was significantly greater in women receiving epidurals (11). In one hospital where 51.7% of women studied requested epidurals in labor, oxytocin was administered both prior to and after epidural placement. Epidural analgesia contributes to abnormal labor patterns, increasing the risk of operative delivery. When the second stage of labor is slowed (the pushing phase) the mother is more likely to be given an oxytocin (Pitocin) drip to speed things up (12). This is especially true of women having their first babies. The use of epidurals was found to produce significantly longer first and second stages of labor (13) (14). Epidural analgesia leads to undesirable effects on the outcome of labor, ultimately leading to an increase in cesarean delivery. (15) The higher incidence (35%) of malpresentation of the baby when women are given epidural analgesia contributes to the need for cesarean delivery (16). This increased number of babies in poor position for birth resulted from laxity of the pelvic floor muscles, caused by the epidural. The medication in the epidural obviously interferes with nature's plan for labor by relaxing the pelvic floor too much. Less than one-third of women studied had a vaginal delivery. Women receiving epidurals are 14.5 times more likely to experience a temperature higher than 100 degrees F. when compared to those without (17). An unmedicated woman commonly perspires and hyperventilates, dissipating much of the heat generated by the physical activity of laboring. Women who receive epidurals often experience chills and shivering. Epidurals limit perspiration, thus promoting the build up of heat in the body. High fever in the mother was associated with low one minute Apgar scores, more resuscitation of newborns, oxygen therapy in the nursery and even neonatal seizures. The higher the fever in the mother, the more likely an adverse reaction in the baby would occur. (18) Epidural use in the mother can result in significant fetal temperature rise (19). When a baby's temperature rises in utero, it increases fetal oxygen consumption, thus limiting the baby's response to stress. The babies of these mothers with high temperatures are evaluated more often for infection and treated more often with antibiotics. This results in separation of mothers and babies and the disruption of the breastfeeding relationship. Hypotension in the mother can also occur when epidurals are in place (20). This decrease in blood pressure to below normal range can be prevented by the administration of extra fluids, through an i.v. line before the epidural is placed. The mother's blood pressure needs to be frequently monitored. This, in addition to the continuous monitoring of the baby's heart rate, can alert the anesthetist of the occurrence of hypotension. The mother can then be given a drug to counteract this adverse effect. Urinary retention is also commonplace. A woman must have a catheter in place when given an epidural. Full return of bladder sensation can take several hours to several days (21). Neurological trauma has been described relative to epidural use in labor. These include direct trauma to the spinal cord, abscesses and meningitis (22). Although their occurrence is very rare, the risks are there and should be acknowledged. Prolonged neural blockade headaches, backache, bladder dysfunction and shivering have been associated with epidural use. Women reported neck pain, shooting pain in their legs, knee numbness and leg numbness as pain that developed after receiving epidurals in labor (23). The process of birth works so well without interference; an epidural complicates the process in so many ways. One of the biggest problems with epidural use is that the woman can not push her baby out. Thus, epidural analgesia prolongs the second stage of labor. Women who receive epidurals are 3.5 times more likely to have Pitocin to augment their labors and 4.5 times more likely to have instrument-assisted deliveries (24). An epidural, by eliminating the pain of labor, also eliminates the bearing down sensation. The pelvic floor relaxes and the baby is not able to maneuver into proper position for birth. This lack of sensation can lead to complications, such as the rupture of one mother's pubic bone from excessive force being applied to her thighs while she was pushing her baby out. (25) The rupture of the woman's "symphysis pubis" occurred while the baby was crowning and the attendants were forcibly holding the woman's legs up. Attention should be paid to the extreme force sometimes used by medical attendants to assist in the bearing down efforts when the woman is not aware of pain sensations. It is suggested that the epidural should be turned off when the woman becomes fully dilated, allowing her to be aware of pushing urges during the actual delivery. Women are prone to increase blood loss following delivery with epidural anesthesia(26). This may be due to the inability of the uterus to clamp down effectively after birth. This is yet another example of how epidurals interfere with the natural process. When first introduced, epidurals were used primarily in long, complicated labors in which delivery by forceps was, as a last resort, likely to be the outcome. Now, when epidurals are commonly used for normal, uncomplicated labors, forceps deliveries are commonplace. In fact, the use of an epidural is associated with four-fold increase in operative deliveries (27). The evidence in the medical journals overwhelmingly proves that epidurals lead to an increase in the use of forceps and vacuum extractors. One study(28) showed women with epidurals had a forceps delivery 25.9% of the time, compared with 4.1% of unmedicated mothers. Another study (29) revealed an alarming 71% rate of instrumental delivery among women giving birth for the first time, when using epidural anesthesia. The use of elective epidurals in labor will result in a markedly increased risk of instrumental (forceps or vacuum extractor) or operative (cesarean) delivery(30). When one study (31) looked at a substantial decrease in the use of epidurals due to a change in the health insurance of the women involved, the difference in the number of forceps deliveries was significant: 14 with epidural use compared to 1 without. Physicians should discuss the risk of forceps delivery as a result of epidural use with their patients before labor, allowing them to make an informed decision. Since epidural use is consistently associated with an increase in forceps and vacuum extractions, there are also more episiotomies performed. Among women giving birth in a Boston hospital, the epidural rate was over 70%. As can be expected, there were more third and fourth degree tears and/or episiotomies among the epidural group (32). Epidurals were found to be significant predictors of severe perineal injury. Damage to the mother's perineal area is of concern when instrumental delivery is used. Soft tissue trauma was reported 35% of the time when vacuum extraction was used and 49% of the time with forceps use (33). Damage to the ana spincter míscle or tearing into the upper vaginal wall was reported at 11% among vaeuum extractions; 17% among forceps deliveries (34). The use of an epidural also causes an increased rate of cesarean delivery. The earlier the epidural is placed during the course of the labor, the greater the risk of cesarean: 50% if placed at 2 cms. dilatation, 33% at 3 cms. dilatation and 26% at 4 cms. dilatation or higher (35). Epidural analgesia causes an increase in the need for cesarean sections due to dystocia (stalled labor) among first time mothers. Even though Pitocin was used aggressively in nearly 56% of women, this was not able to lower the rate of cesarean delivery for slow or stalled progress(36). Epidurals cause a decrease of uterine activity that leads to more cesareans for dystocia. Epidurals also decrease the mother's sensation of pushing, which, in turn, makes the second state of labor longer, causing more cesarean sections to be performed. Women should be told that operative intervention is more likely to occur when they are given an epidural. The epidural interferes with the normal second stage mechanisms that are responsible for the rotation and descent of the baby (37). This contributes to an increase in the rate of forceps delivery as well as the rate of cesarean sections. When a woman requests an epidural while laboring with her first baby, she is almost twice as likely to require an operative or cesarean delivery (38). This may not be clear to women and should be explained to them prior to labor. Perhaps a knowledge about the dangers and risks of epidurals will make women more determined to achieve a non-medicated birth. If they realize the real risk of forceps or cesarean delivery, they may reconsider. One major complication of epidural use is unintentional dural puncture (39). When this occurs, the needle is inserted into the mother's spinal column, rather than remaining in the "epidural" space. Although rare, occurring in between one to two percent of all epidural placements, it can be life-threatening. The risk of an intentional dural puncture is greater when a less experienced anesthesiologist is administering the epidural; while human fatigue is a factor as well, with more accidental punctures occurring at night (40). If recognized immediately, by a leaking of the spinal fluid from the tip of the needle, the concern is that the woman will experience post-spinal headaches after delivery. If the puncture is not recognized immediately, there is a risk that the epidural will travel high, breathing will stop, and prompt resuscitation will be required to avoid death. Obstetric fatalities have been reported related to epidural anesthesia. In most cases, the misplacement of the needle or the catheter resulted in a lethal injection of the drug (41). In one specific case report (42) a healthy 19 year old woman had respiratory arrest shortly after receiving her epidural for pain relief in labor. Nineteen minutes after administration of the medications, her blood pressure dropped markedly, and she was found to be blue and unresponsive. She was resuscitated immediately, her breathing was reestablished using more medications (2 doses of naloxone) and she was revived. She continued with the course of her labor and was delivered, via vacuum extractor, of a healthy baby girl, and had no memory of the course of events. Cardiac arrest and death have been reported after an accidental injection of bupivacaine into the woman's blood stream (43). Anesthesia-related complications are the sixth leading cause of pregnancyrelated death in the United States (44) (45). Although extremely rare (1.7 deaths per million births) they most often occur when general anesthesia is given for a cesarean section. But deaths from regional anesthesia (epidurals) can occur due to the toxicity of the drugs used and the high epidural block. Of the deaths reported, most (70%) were among women who had epidurals; the remaining deaths (30%) were from spinals (46). Most anesthesia related deaths occurred during cesarean delivery. Maternal death rates are significantly higher for women having cesareans than from vaginal delivery (47). The risks to women and their babies as a result of epidural use in labor are well documented. Epidural analgesia is related to longer labors, caused by slower rates of cervical dilatation and a malpositioning of the baby during descent. This contributes to more invasive techniques, such as forceps and vacuum assisted delivery. Ultimately, the dramatic rise in the use of epidurals in labor has made significant contributions to the cesarean epidemic (48) (49). Painless labor is now expected by pregnant women. A woman makes plans to have an epidural prenatally, with her choice being strongly influenced by her family, her friends and the media. Our society does not portray labor as a natural event. When making educated decisions about labor pain management, women must look at the benefits and risks of natural childbirth in comparison to obstetric intervention and its consequences. I wholeheartedly agree with author, Penny Simkin, when she writes, "I believe that epidurals represent overkill, and that the pain of a reasonable normal labor is manageable for most women with non-medical comfort measures and appropriate support." (50). I, myself, have given birth to seven children at home, without pain relief of any kind. I had, in its place, the loving support of family and friends; massaging my back and offering words of encouragement. Their presence made the labor manageable. The fact is that labor is not one, big continuous pain. There are always breaks in between the contractions and there are usually even nicer breaks when the pushing stage begins. When you accept the pain of labor one contraction at a time, rather than fret about the possibility of being in labor for hours and hours, you can mentally cope with the intensity of the contractions. Labor is "good" pain and each contraction is working toward the moment of birth. That moment of release - relief - joy - fulfillment - and empowerment is diluted with an epidural. The brazen truth is that epidurals rob women of their optimal birth. When women are numbed of their pain in labor, their emotions are numbed as well. You must live your labor and be an active participant in your baby's birth. Do not allow drugs to distract you from that. You deserve the feeling of euphoria that accompanies truly natural childbirth.