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Sep
01

Epidural Anesthesia: Important Facts that will Help You Take Charge of Your Birth

Author // Alyssa Benedict, M.P.H.

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Epidural Anesthesia: Important Facts that will Help You Take Charge of Your Birth
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Each year, 4 million American women give birth.1 Epidural anesthesia is used in almost two-thirds of labors, making it one the most common obstetric interventions in the United States today.2 In fact, the rate of epidural anesthesia is increasing.3 One might expect that the increase is related to the fact that epidurals are improving obstetric care. A closer examination of the evidence tells an important story—one every woman needs to consider on her journey toward birth.



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What is often missing from conversations about epidurals—conversations with practitioners as well as friends and family—may impact your decision to have one. This article describes some of the most important considerations when thinking about an epidural for your birth. It is not about whether or not you choose an epidural; rather, it is about the process you move through to decide. It offers current information on risks and benefits that will help you make an authentic decision that is in the best interest of you and your baby.

Epidurals are an important obstetric intervention to consider because they are viewed by thousands of women as an all-around safe intervention. Thousands of women have very limited information regarding the real risks and benefits of epidurals, or of the ways in which having one profoundly affects the birth process for them and their babies. In many cases, practitioners and women refer to epidurals as they would refer to a variety of seemingly inevitable routine obstetric practices—you go to the hospital to have a baby, you get a wristband, contractions are timed, and you get an epidural. The problem with the view that epidurals are an inevitable part of the birth process is that women are not taking the time to consider a continually growing amount of vital information regarding their effects. Although epidurals are used extensively in this country, there is a paucity of awareness about how they affect mothers and babies physiologically, and how they affect labor progress and outcomes. Further, there is virtually no discussion on how epidurals impact mothers and babies psychologically. Data from more than three decades of research in prenatal and perinatal psychology suggests that the circumstances surrounding conception, pregnancy, labor, birth and the postpartum period can have a profound impact on an individual’s development into adulthood.4

The rise in popularity of epidural use is, in part, related to the fact that practitioners do not disclose information to pregnant women in a complete and meaningful way.5 Published reports show that information disclosure is biased according to profession.6 A 2002 report in the American Journal of Obstetrics and Gynecology 7 states, “It is not known to what extent women are fully informed about all the possible unintended effects of epidurals, standard care practices that always include use of electronic fetal heart rate monitoring and IVs, potential interferences with normal labor progress, and the risk for more serious and even life-threatening complications.”8 Furthermore, informed consent for epidural anesthesia is often obtained during labor and, as a result, the informed consent process is “carried out in a superficial and abbreviated manner.”9

The Importance of Authentic Decision-Making An authentic decision is one that is made based on conscious awareness of cultural influences on the decisionmaking process itself and the evidence-based risks and benefits of the particular practice or intervention one is considering. Many women are not making authentic decisions about birth interventions, including epidurals. This is, in many ways, understandable. Many women assume that if there were risks involved in having an epidural, their practitioners would tell them; therefore, they do not ask. “Women may request or consent to an epidural precisely because they lack a full appreciation of what choosing an epidural means.”10

Risks: The Hazards of Epidurals for Mothers Research shows that the natural process of birth has been exquisitely designed. The body has evolved over millions of years to support a natural process that has successfully sustained human life. For example, the brain releases endorphins during birth. These amazing chemicals have an effect 200 times that of morphine and produce a tranquil, amnesiac condition.11 This condition occurs naturally in all mammals as the mother approaches the end of the opening phase of labor. A woman “slips into a tranquil state, goes deeper within to her baby and her birthing body, leaving all the distractions of the rest of the world behind as she and her baby connect and give birth.”12 Mammals continue to experience birth in this way very successfully.

Epidurals interfere with this exquisite process— one designed with the practicality and logic of evolution. Epidurals significantly interfere with some of the major hormones of labor and birth, which may explain their negative effect on the processes of labor.13 The World Health Organization states, “epidural analgesia is one of the most striking examples of the medicalization of normal birth, transforming a physiological event into a medical procedure.”14 The evidence clearly indicates that epidurals are associated with various risks. For example, women with epidural anesthesia experience a significant increase in instrumental deliveries (e.g., forceps, vacuum) and instrument deliveries have their own host of risks to mother and baby.15 Epidurals are also associated with an increased risk of operative (cesarean) deliveries which, like instrumental deliveries, are also risky for the mother and her baby. On page 21 is a list of additional risks and their accompanying medical concerns that have been well-established by research.16–24

Long-term maternal problems can include persistent backache, neck ache, numbness, tingling and dizziness.25 Serious but rare maternal risks can include convulsions, respiratory paralysis, cardiac arrest, allergic shock, nerve injury, epidural abscess and maternal death.

Risks: The Hazards of Epidurals for Babies A baby experiences unprecedented brain development prenatally and through the first two years of life. This creates a unique vulnerability to drug exposure during birth. Narcotics and the type of anesthetics used in epidurals rapidly cross the placenta and can affect the baby.26, 27 Furthermore, drugs have a greater impact on the baby compared to the mother because of the baby’s size and limited ability of the liver to excrete drugs.28 Studies show that babies whose mothers received drugs for pain relief showed the following:

  • Reduced muscle tone

  • Increased incidence of jaundice

  • Damage to the central nervous system

  • Impaired sensory and motor responses, reduced ability to process and respond to incoming stimuli, interference with feeding, sucking and rooting responses

  • Lower scores on tests of infant development

  • Increased irritability

  • Withdrawal symptoms (from narcotics) that can last up to two weeks and may include irritable crying and tremors

And, with so many babies being born with epidurals, behaviors such as crying and discomfort are often assumed a normal part of newborn behavior. Studies have clearly demonstrated that frequent and prolonged crying is not normal and often related to what researchers and practitioners are calling “birth trauma.”

A growing number of researchers are exploring the effects of birth experiences and labor drugs on babies, child development, and human development throughout the lifespan. One study found a correlation between adolescent drug abuse and the amount and timing of the drugs given to their mothers during labor.29 Animal studies suggest that epidurals can produce effects observable later in a child’s development—effects related to epidurals interfering with vulnerable brain processes during a sensitive period.30 The rise in epidural use and high-tech birth in general is not producing better birth outcomes, and, of growing concern, coexists with what some researchers are calling a “crisis in infant and child development.”31 This crisis is marked by alarming rates of autism, ADHD, childhood aggression and depression, asthma, overweight and obese children, attachment disorders and learning disabilities.32

Risk
Risk-Related Problems

Maternal hypotension

(drop in blood pressure)

  • Negatively impacts maternal blood pressure being maintained at sufficient levels to assure oxygenation of the fetal blood.

  • Reduces blood supply to the placenta; baby is distressed (e.g., decrease in fetal heart rate).

  • At-risk babies may not have the reserves to handle an even small drop in mother’s blood pressure.

  • Maternal and fetal respiratory distress.

Pruritus

(an uncomfortable sensation of the
skin that provokes the urge to scratch)

  • Mother may be given a drug to combat the itching, which may have side effects of its own.

Prolonged labor length

(also known as “failure to
progress” and “dystocia”)

  • This increases the likelihood of oxytocin/Pitocin augmentation which has its own host of side effects.
Urinary retention
  • Increase in urinary tract infection.

  • Full bladder inhibits dilation of cervix and rotation of the baby’s head.

  • Bladder control may be lost for days, weeks or months because of strain on numbed pelvic floor muscles.

Maternal fever
  • Epidural anesthesia affects a mother’s ability to sweat. If she can’t sweat, she can’t as easily dissipate excess body heat.

  • Uncomfortable for mother and can result in treatment of mother for chorioamnionitis.

  • Baby’s heart rate may become distressed from mother’s fever, increasing odds of cesarean section.

  • Babies are often separated from their mothers immediately after birth to check for infection.

  • Babies may be subjected to invasive tests (e.g., blood work, spinal tap to check for sepsis).

  • Baby may stay in hospital for several days for antibiotic treatment while mother goes home.

Inadequate analgesia

(uneven, incomplete or
nonexistent pain relief)

  • Some mothers find incomplete, blotchy pain relief to be just as stressful as no pain relief at all.
Unintended high level
of anesthesia

  • Maternal respiratory depression and related impact on baby.
Inability to move
about freely

  • Inhibits labor progress.

  • Increases likelihood of cascade of interventions.

Nausea/vomiting
  • Uncomfortable for mother.

  • Can waste needed resources and deplete mother’s energy.

  • Medicine may be given to treat nausea which sometimes makes the mother intensely sleepy. This has its own effects.

Post-dural
puncture headache

(also known as an “epidural headache”)

  • Most likely caused by post-dural puncture and leaking cerebrospinal fluid. Can range from mild to debilitating and last from days to weeks.
Post-anesthesia back pain
  • May last a few days or continue for years.

  • Possibly due to “stressed” positions in labor exacerbated by muscular relaxation and the absence of feedback pain to tell you to get out of a damaging position.

  • May (rarely) be caused by nerve damage.

Increase in uterine
infection, misplacement
of catheter/anesthetic

  • Unsafe for mother.
Decrease in mother’s
release of oxytocin

  • Epidurals disrupt important hormone shifts that naturally occur during labor (e.g., oxytocin causes a woman’s uterus to contract in labor). Often leads to Pitocin, which has its own risks.