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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.

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.



The Epidural Chain: A Cascade of Risky Interventions. One of the most important considerations regarding use of epidural anesthesia is that it is never an isolated intervention. The “epidural chain” is the phenomenon whereby use of an epidural is accompanied by or leads to other interventions, each with its own risks, and causes a combined or cumulative risk effect. Various procedures and interventions automatically accompany epidurals and are often dictated by hospital policy. These include, but are not limited to, bed confinement and limited movement, intravenous fluids, restrictions on oral intake of food and fluids, continuous electronic fetal monitoring, oxytocin/Pitocin for labor stimulation, an indwelling bladder catheter, and oxygen by mask.33 If you are considering an epidural, it is important to understand the risks and benefits of these and other interventions that will accompany the procedure. The epidural chain is virtually absent from discourse between practitioners and pregnant women and must be understood if you are to make an authentic decision about having an epidural. It is also important to note that the interventions caused by epidurals are often viewed by women as independently occurring and unavoidable—they do not realize that such interventions were required because of the epidural.

Birthing a child is one of the most powerful and important life experiences one can have, yet many women enter the process largely unprepared and uninformed.

Psychological Impact of the Epidural Chain. One of the most forgotten and most insidious effects of the epidural chain is its impact on the psychology of the mother, her baby, and their relationship. The long labors, difficult deliveries, and maternal-newborn separation (psychological and physical) that accompany epidurals affect both mother and baby as individuals as well as their bonding and attachment with one another.

Psychological Risks for Mothers: Robbie Davis-Floyd, an anthropologist specializing in birth, states that a woman in labor with an epidural “...is separated as a person as effectively as she can be from the part of her that is giving birth.”34 How might this experience affect her view—consciously or unconsciously—of herself as a woman and a mother? How might it affect her parenting? The psychological effects of epidurals can be experienced consciously or unconsciously by women and can include stress, regret, detachment, depression, disappointment, loss, and lack of control. This information could cast a new understanding on the etiology of postpartum depression and other symptoms reported by women postnatally. There is a real need to consider the psychological repercussions of not moving through birth in the way that nature intended. Medical science acknowledges that interrupting the body’s natural rhythms across a variety of healthcare concerns can cause a host of problems—this knowledge needs to be applied to birth.

Psychological Risks for Babies: Research in prenatal and perinatal psychology reveals that during birth, babies are exquisitely sensitive to their environment and relationships.35 The emotional state of a baby’s mother is felt prenatally and during birth. If we know that many mothers who have epidurals can consciously or unconsciously experience difficult emotions such as stress, depression and emotional isolation, we have to acknowledge that these emotions are also felt by the baby. Babies’ earliest experiences, including those during labor and birth, form a foundational blueprint for life. What experience do you want to create for your baby? Research shows that babies adopt adaptive strategies in the womb and at birth that can influence later behavior. What is it that babies are adapting to when birth includes an epidural? Sadly, the majority of babies born in the United States show signs of stress or traumatic imprinting.36

Pioneers in prenatal and perinatal psychology such as David Chamberlain, William Emerson and others have done extensive work and research on birth trauma. For example, it is well documented that forceps and vacuum extractors can be extremely harmful to the baby, physically and psychologically. Research shows that babies who experience such instrumental deliveries are more likely to experience a range of problems including prolonged crying, sleep dysfunction and reflux. These and other experiences can profoundly affect their sense of comfort and safety in their own bodies, as well as their view of the world. These feelings can follow them into their next developmental stage.

Epidurals and the Mother-Baby Relationship: The complex and often traumatic birth that often accompanies the epidural chain can have profound impact on the mother-baby relationship. For example, during birth, drugs impair a mother’s ability to connect with her baby and “take away a vital communication link with the baby.”37 They prevent mothers from being able to “respond to position changes in the baby by moving and reacting with their bodies.”38 This inability to respond because of a chemically-induced disconnect between mother and baby can create feelings of inadequacy for the mother and instill feelings of rejection in babies (this is in addition to the physical problem of being unaware of your body and what positions may help your baby descend safely).

Epidurals can also impact the mother-baby relationship after birth. Maternal feelings of disempowerment (conscious or unconscious) during birth can set a dysfunctional tone for postnatal parenting and feelings of rejection experienced during birth can affect a baby’s early responses to parenting efforts. Fascinating and important research in neuroscience shows that early wiring of our social-emotional success center (i.e., in the orbitofrontal cortex) occurs immediately following birth.39 At this time, a complex hormonal cocktail “orchestrates intricate exchanges between a mother and her newborn child.”40 Research shows that when obstetric interventions prevent this precious engagement, “neurobiological havoc ensues.”41 Epidurals obliterate the maternal oxytocin peak that occurs at birth, the highest of a mother’s lifetime. Oxytocin is known as the hormone of love, and helps mother and baby connect and attach immediately following birth. Interestingly, several studies show that children with autism have abnormalities in their oxytocin system.42 Of further interest is the fact that the rise in incidence of childhood disorders such as ADD, ADHD and autism have occurred alongside the rise in use of obstetric interventions, including epidurals. A growing body of research on pre- and perinatal psychology is demonstrating that birth interventions once thought safe may be at the roots of a host of postnatal infant behaviors such as prolonged crying and colic. Sadly, these behaviors are seen as normal. In fact, they are rare, if present at all, in those cultures where birth is not medicalized and women are given the space to let their bodies guide the process.

PRIMARY RISK CREATES…
SECONDARY RISKS CREATE…
TERTIARY RISKS CREATE…
Diminished sensation
and motor ability
Decreased ability to “push”
or breathe the baby down;
inadequate uterine contractions
Use of instruments (forceps, vacuum); cesarean section;
directed pushing and associated risks to mother (e.g., pelvic
floor) and baby (e.g., decrease in fetal cerebral oxygenation)

Prolonged labor length

(dystocia)

Maternal exhaustion; inadequate
uterine contractions; clinician
exhaustion
Oxytocin/Pitocin augmentation;
instrumental vaginal delivery;
cesarean section
Intrapartum fever
Cesarean delivery; instrumental
vaginal delivery; neonatal sepsis
evaluation; newborn antibiotic
treatment; treatment of the
mother for chorioamnionitis
Inability/impaired ability to care for newborn;
mother-baby separation; interruption in bonding and attachment;
maternal depression; baby depression

Informed Choices Improve Outcomes Obstetric interventions like epidurals used during routine, low-risk births are actually causing the very problems they are believed to prevent. There are higher rates of high-tech, unnecessary obstetric interventions in the United States maternity care system than in any country in Western Europe and these interventions are not leading to better outcomes. The United States spends twice as much per capita on maternity care than any other country yet it has lower mortality rates for women and babies around the time of birth.43

Unnecessary epidurals pose significant physiological risks to mother, baby and the birth process itself. Common labor and delivery complications such as failure to progress, shoulder dystocia and meconium are frequently seen as independently occurring events when they are often associated with epidural use. Psychological risks and their effects add to the epidural chain, extending its effects into adulthood for mothers and into infancy, childhood and beyond for babies. Multiple obstetric events (e.g., operative deliveries, prolonged labors) can act synergistically with epidurals to affect mothers and babies. There was a time when women gave birth safely and successfully without epidurals. The culture of birth in the United States suggests that birth is essentially unsafe, that technology outperforms the natural mechanics of the human body, and that women need help doing something that they have done with great success for millions of years. In countries where birth is viewed as a natural process, birth outcomes are far better. It is essential for women to consider the origins of their views on birth and the evidence-based information on the physiological and psychological effects of epidurals.

Research indicates that prenatal planning has a significant influence on the use of epidural anesthesia during labor.44 Ultimately, it seems that plans for pain relief and practicing techniques that facilitate coping with labor (techniques that women once knew naturally but have been conditioned out of consciousness) can reduce the likelihood of having an epidural. Hypnobirthing and the Bradley Method offer two examples of highly regarded models with excellent evidence of effectiveness. Each is designed to help women reconnect with their inner wisdom and power to birth successfully.

Research has clearly established that how women experience pain during childbirth is often unrelated to the birth itself and instead influenced by such factors as culture, expectations, coping skills, feelings about birth, an authentic understanding of the birth process, confidence, and the support of caregivers and practitioners. Studies also show that epidural use can increase or decrease as a result of factors that have nothing to do with labor itself. For example, in one study, the rate of epidural use went from 71 percent to 27 percent following changes in state-funded insurance reimbursement that decreased epidural services.45 Interestingly, there was a decrease in operative deliveries in the time period that followed the removal of epidural services.

Women cannot wait for improvements in informed consent. They need to take charge of their birth process and become informed, evaluate the data, and make authentic decisions regarding all aspects of the pregnancy and birth process. Women also need to invest at least as much time (and, preferably, more) in this endeavor as they spend evaluating and choosing the furnishings for the baby’s room, the best developmental toys, the highest quality stroller, and even maternity clothes. Now more than ever, it is essential that women use the information age to their advantage and arm themselves with the knowledge they need to make an authentically informed decision that will affect their lives and that of their babies.

In order to make an authentic decision related to birth, women need to speak candidly with their practitioners while simultaneously taking the initiative to develop an evidence-based fund of information about pregnancy and birthing that is available and accessible through a variety of educational resources. It is critically important to seek out the information that is available about birth versus solely relying on practitioner opinion. The concept of taking charge of your own health by actively learning about health maintenance and illness and disease prevention is encouraged in various aspects of healthcare today; it is often absent in maternity care.

It is also important that a proper rapport exists between you and your provider. This rapport should encourage and include discussions about evidencebased maternity care. Ultimately, each woman must determine if her practitioner is well versed in the most current evidence on the physiological and psychological effects of epidurals, instead of simply assuming that he or she has this information. Practitioners who are informed and value women as active participants in the birth process respond positively to questions and often encourage discussions about different birth choices. Ultimately, a woman’s quest for accurate, evidence-based information eliminates the possibility that the she can be manipulated by cultural messages about birth and act against her own interests and those of her baby without even realizing it.46

Taken together, information about the influence of culture on birthing practices and choices and the real benefits and risks of epidurals can empower women with the knowledge they need to make informed choices for themselves and their babies. And as more and more women truly take charge of their births, we are likely to see the United States improve its global ranking in birth outcomes and save millions of healthcare dollars, as expensive and unnecessary interventions decrease. Finally, and perhaps most importantly, we are likely to see a happier culture. After all, the traumas of birth become the traumas of childhood and adulthood. Early efforts to protect the birth process can reap extraordinary rewards for individuals, families, communities and society.


Pathways Issue 39 CoverThis article appeared in Pathways to Family Wellness magazine, Issue #39.

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