Epidural Epidemic

By Joanne Dozer and Shannon Baruth
Issue 95, July/August 1999

The use of epidurals is so common today that many perinatal professionals are calling the 1990s the age of the epidural epidemic. Believed by many in the medical profession to be safe and effective, the epidural seems now to be regarded as a veritable panacea for dealing with the pain of childbirth.

It is true that most women experience pain during the course of labor. This pain can be intense and very real, even for those who have prepared for it. But pain is only one of many possible sensations and experiences that characterize the experience of giving birth. Barbara Katz Rothman, a sociologist who studies birth in America, writes that in the medical management of childbirth, the experience of the mother is viewed by physicians as pain: pain experienced and pain to be avoided.¹ Having experienced childbirth ourselves, we have great compassion for women in painful labors. However, we also feel a responsibility to mothers and their babies to explore issues concerning the use of epidural anesthesia in labor issues that are seldom discussed prenatally.

Several factors make the use of epidurals potentially hazardous. The Physician’s Desk Reference cautions that local anesthetics - the type used in epidurals - rapidly cross the placenta. When used for epidural blocks, anesthesia can cause varying degrees of maternal, fetal, and neonatal toxicity which can result in the following side effects: hypotension, urinary retention, fecal and urinary incontinence, paralysis of lower extremities, loss of feeling in the limbs, headache, backache, septic meningitis, slowing of labor, increased need for forceps and vacuum deliveries, cranial nerve palsies, allergic reactions, respiratory depression, nausea, vomiting, and seizures.² In addition, a piece of the catheter that delivers the drug into the duraregion of the back may break off and be left in the woman, a dangerous risk that necessitates surgical removal. One of the most well-known side effects of spinal anesthesia is a spinal headache. Depending on the amount of anesthetic used and how the catheter was placed, the headache can be mild or severe, lasting between one and ten days after the birth. This is not how any of us wants to feel in our first days and hours with our newborn.

Epidurals also have been linked to an overall increase in operative deliveries: cesareans, forceps deliveries, and vacuum extractions. A meta-analysis of the effects of epidural anesthesia on the rate of cesarean deliveries was undertaken by a group of physicians who examined, categorized, and analyzed all available literature. Eight primary studies revealed that the rate of cesarean section was 10 percentage points higher in the women who had received epidural anesthesia. One study actually found that the cesarean rate increased to 50 percent when the epidural was given at 2 cm dilation, 33 percent at 3 cm, and 26 percent at 4 cm.³ What caused this increase? In the first stage of labor, the muscles of the pelvic floor may become slack from the numbing effects of the epidural, causing the baby to change an otherwise ideal position or fail to descend into the pelvic cavity. In the second stage of labor, the anesthetized woman often is unable to push effectively since she cannot feel her muscles. When the baby does not descend properly or is malpositioned, progress can slow or stop, resulting in a longer labor and the increased possibility of a cesarean section, vacuum extraction, or forceps delivery.

In addition, epidurals usually slow contractions, which prompts medical personnel to administer intravenous Pitocin in order to strengthen them and increase their frequency. Even with Pitocin, which carries its own set of risks, an anesthetized labor may remain prolonged, risking a difficult labor with lack of progress. Prolonged labors put both mother and baby at greater risk of infection, necessitating the use of antibiotics. The longer a labor and slower the progress, the more likely it will end in a forceps, vacuum, or cesarean delivery. Since cesarean section is a major surgery, it strongly influences a woman’s recovery and the initiation of breastfeeding. Of course, the rate of postpartum infection is much higher with cesarean births. All vacuum extraction and forceps deliveries increase the risk of morbidity and birth injuries.

Another effect of epidurals during labor is the creation of hypotension in the mother, which can lead to bradycardia (a decrease in the heart rate) in the fetus. All types of anesthesia, including epidurals, can negatively affect the baby’s heart rate, possibly leading to fetal distress and necessitating an operative delivery. The newborn can continue to have breathing difficulties after birth, requiring supplemental oxygen or even resuscitation. While these problems may be resolved immediately following the birth, they often require the mother to be separated from her baby for neonatal nursery observation. This separation delays bonding and initial feeding. In addition, poor muscle tone and increased acidity in the baby’s blood due to bradycardia and oxygen deprivation may affect her ability to suck effectively, hampering initial attempts at early breastfeeding.

A mother’s temperature may become elevated with the use of epidural anesthesia, resulting in the infant being taken to the nursery and given a full work-up for possible infection. This may include extensive blood work and a spinal tap.^4,5

Furthermore, though epidurals usually remove all sensation in the lower body, "windows" can occur which leave the woman experiencing the intensity of her labor (perhaps on one side of her body) but with extremely limited mobility - obviously hindering her ability to cope with her contractions.⁶