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Straight Talk on Epidurals for Labor

February 21st, 2011 by avatar

Recently, we’ve seen some buzz on the internet about a new book, Epidural Without Guilt. Childbirth Without Pain by Gilbert Grant, an anesthesiologist. At least one other blogger has disputed his logic, so I thought I’d weigh in on the evidence basis for his claims.

Dr. Grant says that according to his analysis of the medical studies, epidurals:

  • Can speed up labor
    This may be true for some women but not in general. Meta-analysis, a technique for pooling data from multiple trials, finds that epidurals slow labor and increase the need for strengthening contractions with oxytocin.
  • Don’t increase the need for cesarean
    True, but this is because other factors outweigh epidurals. In a nutshell, if a woman has a care provider who tries to minimize use of cesarean, she is at low risk of surgical delivery regardless of whether she has an epidural, and if her care provider resorts to cesareans liberally, she is at high risk, again, regardless of whether she has an epidural.
  • May reduce the likelihood of postpartum depression
    Studies of what makes for a satisfying birth experience consistently find that quality of supportive care is the key factor, and pain management only enters the picture when the woman’s pain relief expectations are not met.
  • Can help with breastfeeding
    Epidurals are associated with breastfeeding difficulties, although these can be overcome with good support. Dr. Grant, though, is actually proposing epidural anesthesia after the birth, to relieve postpartum discomforts that he believes interfere with breastfeeding. Few women, however, would need anything more than an ice pack and maybe some over-the-counter medication for cramps after vaginal birth especially if they have not had instrumental delivery or an episiotomy.  As for post-surgical women, I would think that impairing mobility would increase risk of deep venous clots and that conventional pain relief methods are deemed adequate for every other type of surgery.

Dr. Grant’s blurb says his book offsets the focus on epidural risk. I disagree that the problem is, in fact, overemphasis on the risks of epidurals. The American Society of Anesthesiologists consumer pamphlet, which should set the standard for informed consent, mentions only hypotension, which can sometimes cause slowing of the fetal heart, post dural puncture headache, dizziness or seizure if the drug enters a vein, and difficulty breathing if the drug enters the spinal fluid. On the contrary, I think women are given far too little information about potential harms, which is why I wrote the article reprinted below for Choices in Childbirth’s “Guide to a Healthy Birth” booklet which summarizes my own analysis of the literature. The piece is based on the epidural chapter for the new edition of Obstetric Myths Versus Research Realities, now nearing completion for University of Michigan Press (Amy Romano, co-author).

I append the chapter’s mini-reviews reference list and include as well some studies from the labor support chapter relevant to my critique of Dr. Grant’s findings. I should add that the book is not a narrative review, that is, authors cherry pick studies and data from studies that support their thesis. Amy and I preset inclusion and exclusion criteria, tried to find all studies that fit those criteria on our topics, and give reasons for excluding studies that otherwise fit our criteria.

From the Guide to a Healthy Birth booklet:


No doubt about it. Epidurals are aptly named the “Cadillac of analgesia.” Epidurals allow women to be awake and aware yet free from pain during labor and birth. They permit an exhausted woman to rest or sleep. And while their usual effect is to slow labor, the profound relaxation they offer can sometimes put a stalled labor back on track. Despite these benefits, you would do well to look under the hood before you decide to drive this “Cadillac” off the lot. Like all medical interventions, epidurals have potential harms. The wise woman will want to weigh them against her other options. Unfortunately, many care providers don’t supply complete information. To give you a more balanced picture, here are the disadvantages of epidurals according to the research:

  • A minimum of 5 more women per 100 will have a vacuum extraction or forceps delivery: Consequences of these types of delivery include increased probability of a tear into the anal sphincter muscle and injury to the baby.
  • Seventeen more women per 100 will experience a drop in blood pressure, which may pose a risk to the baby.
  • The narcotics included in epidurals greatly increase likelihood of nausea and can cause itching.
  • Epidurals interfere with establishing breastfeeding. Studies specifically link fentanyl, a common narcotic component, to early problems and higher probability of switching to bottle feeding. Associated interventions such as instrumental vaginal delivery may also affect early breastfeeding.
  • Somewhere between 1 in 1,400 and 1 in 4,400 women will experience a life-threatening complication.
  • Combined spinal-epidurals, sometimes called “walking epidurals,” increase complications. Compared with standard epidurals, more women will experience itching, some will have breathing problems or difficulty swallowing, and some babies will experience a prolonged episode of abnormally slow fetal heart rate.

Epidural side effects can also have negative psychological consequences. Fetal heart rate disturbances, a drop in blood pressure, or difficulty breathing or swallowing may cause intense alarm and distress. Itching or nausea can make a woman miserable.

While complete pain relief may make for a more positive labor experience, epidurals interfere with the natural interplay of hormones, which has its downside. During un-medicated labor, beta-endorphin levels rise in response to pain, producing a “high” that enables women to transcend labor pain and experience that “top of the world” feeling after giving birth. An adrenalin surge in late labor dispels exhaustion, gives a woman extra oomph to push out the baby, and ensures that she is excited and alert to greet her baby. Oxytocin is the hormone of love, not just contractions, and un-medicated women have higher levels after childbirth than any other time in their lives.

Still, labor is unpredictable. You don’t want to cross an epidural off your dance card. Just be sure that you make your decision freely, not because you feel pressure or lack an alternative. Here are some ways to do that as well as minimize potential harms:

  • Choose a care provider with a cesarean surgery rate of 15% or less. Studies show that in the hands of care providers with low rates, epidurals do not increase cesarean odds Practitioners who have vaginal birth as a goal will have more patience and manage labor and epidurals differently than others.
  • Choose a mother-friendly birth environment. In most hospitals, confinement to bed, continuous fetal monitoring, and restricting labor support companions such as doulas, along with lack of amenities such as showers, deep tubs, and birth balls make it difficult to cope with labor without an epidural. Where epidurals are the norm, nurses may not know how to support a laboring woman without one, and staff may actively promote their use.
  • Delay an epidural until active, progressive labor. This will help prevent two problems: running a fever, which becomes more likely the longer the epidural is in place, and the baby persisting in the occiput posterior position (head down, facing the mother’s belly). These complications increase the likelihood of cesarean or instrumental vaginal delivery. And because epidural-related fever cannot be distinguished from fevers caused by infection, babies are more likely to be kept in the nursery for observation, undergo blood tests and possibly a spinal tap, and be given precautionary I.V. antibiotics.
  • Choose a standard epidural of the lightest intensity that keeps you reasonably comfortable over a spinal or “walking” epidural.

Finally, whether an epidural is Plan A or B, take classes that prepare you for coping with labor without one and consider hiring a doula. You will want a variety of comfort measures and coping strategies at your fingertips. For one thing, you may need them if you are delaying an epidural until active labor. For another, the anesthesiologist may not be available when you want your epidural, or you may be among the 1 in 10 women for whom it does not work. It is also possible that labor will turn out to be easier than you thought and you decide you don’t need one after all.


For references, go here:references_hencigoer_epiduralwoguilt

Posted by:  Henci Goer

Epidural Analgesia, Evidence Based Medicine, Practice Guidelines, Uncategorized , , , , , , , , ,

  1. February 21st, 2011 at 12:12 | #1

    Thanks to Henci Goer for this analysis! Her voice of calm reason is so refreshing in the maternity care debate today. Information and support (not judgement or fear mongering) is what women need. I cannot wait for the new edition of OMVRR!

  2. February 21st, 2011 at 14:27 | #2

    I was just discussing with a fellow doula today the common misconception about epidurals making labor and birth “pain free”. Too often women are expecting complete pain relief and are rudely awakened when they find out the epidural does not relieve the vaginal discomfort of delivery. – And to top it off they do not have the natural endorphins on board that an unmedicated mother can get some relief from during delivery. Epidurals are a wonderful thing when they are used as all interventions should be – judiciously.

  3. February 21st, 2011 at 20:08 | #3

    Check out this you tube comic on epidurals- funny but true-
    http://www.youtube.com/watch?v=L8GAcJ4IsRA

  4. February 21st, 2011 at 23:16 | #4

    Thank you for your work, Henci. I would like to ask what your thoughts are regarding the use of epidurals for women with previous history of sexual trauma. I often work with women who feel pressured by doulas, childbirth educators, and friends, into not getting an epidural, but whose previous history leads to incredibly difficult, if not exacerbating anxiety regarding pain. Any thoughts would be appreciated.

  5. February 22nd, 2011 at 10:42 | #5

    In addition to the discussion here, I want to add one other concern about the notion that epidural is “all good.” Strange as it seems, one reason we value our children is how difficult it is to have them. When we are invested emotionally and physically in their production, we assign value to them because it’s not easy to get them. When this process is made too easy, do we begin to devalue them? Do they become disposable? If we are not fully present at their birth, how does this affect our relationship with our children?

  6. February 22nd, 2011 at 11:31 | #6

    THANK YOU FOR THIS!! I was ENRAGED at Dr Grant’s article….. gave me goosebumps that pregnant women would actually read it and we would take 80 million steps backward!!

  7. avatar
    Romy
    February 22nd, 2011 at 12:02 | #7

    I know that the issue of informed consent is a big ocean to jump into, but is there research into the timing of ‘informing women’? Discussing risk (and decision-making) during labour is different than a discussion before labour begins. Citing population-level risk and quoting literature doesn’t matter to a woman when she’s been labouring for a long time, those are discussions that should happen long before labour begins.

    To that end, I don’t think it’s possible to truly inform women of every single possibility of labour, too many things can happen. But we can work towards giving women the power and freedom to ask questions safely at any time during their birth process, without fear of having their care altered based on the question they ask. We should encourage women to not be afraid to ask ‘what happens if I DON’T do x or y?’ Ex: “If I don’t get an epidural now, will I never be able to get one? Can you offer it to me again in 15 minutes? Are there other pain management options I can try right now?” (this of course assumes that epidurals are available 24/7, which I know isn’t true).

    It all seems to (always) come back to the most important thing that I wish for all labouring women: continuous (or close to continuous) support in labour with a care provider that you have an established relationship with.

  8. avatar
    Dreamy
    February 22nd, 2011 at 14:23 | #8

    Dr. Grant’s blurb says his book offsets the focus on epidural risk.

    Actually, as you alluded to, I think a lot of the problem with maternity care is the focus (hyperfocus) on pain and pain relief, epidural vs. no-epidural, excruciating pain vs. “guilt,” etc. Or rather, the way pain and pain relief is often used as a smokescreen. “Everybody knows” labor is painful, but the fact that so much is done in the name of “saving” women from pain– essentially the cascade of non-epidural interventions that are NOT being adequately discussed in the mainstream– is an even bigger problem IMO than the epidural issue itself.

    Not to say that epidurals are without risks, etc., and personally I am planning a homebirth. But the fact is, that for most women, the primary question about birth is “epi or no epi,” and most either decide on an epi as soon as the plus sign appears or “try to go without, as long as labor isn’t too painful” (which almost always ends up in an epi). It obscures the issues that in some respects are far bigger ones. There is not the same sort of mainstream consciousness/pseudo-debate around “pitocin or no pitocin” or “AROM or no AROM,” which are procedures/drugs that appear to be even more likely to cause problems for both mother and baby.

    It’s as if we’ve (as a society) reduced a woman’s agency in labor mostly to her preference for pain relief*. We are saying, essentially, “Everything else we do to you or may need/’need’ to do to you is For Your Own Good. If you want to endure it without pain relief, fine (not really), otherwise, please enjoy your epidural, so we will have an even easier time Doing What We Need To Do (For Your Own Good).”

    I wish I had a better analogy, but this will do for now… It’s as if 90% or more of all marriages were arranged by a government committee and you got basically no say in who your spouse would be nor the matter in general except whether the wedding would be performed by the religious officiant of your choice or a Justice of the Peace. Surely, that’s a very important consideration for many of us. But what I see is almost the ENTIRE mainstream “marriage debate” being centered around minister vs. layperson, and not the fact that the vast majority of folks are getting little if any say in whom their actual spouse is going to be, when they get married, or whether they even get married at all.

    When you see it that way… the mind boggles.

    *And even then, of course, there is heavy pressure to get an epi and not as much of a true choice as there should be.

  9. February 22nd, 2011 at 21:06 | #9

    Thank you for this breakdown, it’s very helpful. I wrote the blog post you referred to in the intro to this piece. In the comments section I engaged in some debate with Dr. Grant. He’s pretty determined to emphasize the benefits of the epidural. I continue to think his website is misleading and his proposal that we have epidurals for after pains is just not logical. I also think it’s terrible that in many places the epidural is the ONLY offering when it comes to support. And the vast majority of women get epidurals. So it’s ironic (and perhaps strategic) that people like Dr. Grant take the sympathetic position of “outsider” or underdog in debates like this. But this is the status quo. I don’t think we should ban epidurals– they can be used effectively. But how about putting a few tubs in the labor and delivery rooms? And making sure doulas are at least partly covered by insurance?

  10. February 22nd, 2011 at 22:26 | #10

    We have no idea what pain means to individuals. We can never know what pain unleashes for a woman psychically. The notion that we love our children more because we work hard having them is sophomoric, and inflates the process in a way that can tear women down if they do it any other way. Women have depth and complexity in their relationship to birth pain that none of us will ever understand fully. The method of pain management isn’t the issue, it’s the pressure we have placed on the birthing mother to not experience that pain in a supportive environment. We either expect her to be joyous, or to be numb. And didn’t Elizabeth Bing get an epidural? I say Grantly Dick Read is as much to blame as Dr. Grant. Read’s elevation of birth to the status of Godly, and any variation from it an abfall from God, has placed women in a precarious position. Natural birth is tantamount to sainthood, getting medical assistance for pain is somehow abhorrent, or an indication that a woman has allowed herself to be victimized.

  11. February 22nd, 2011 at 23:34 | #11

    We have found that hypnosis is a great alternative to the epidural for people interested in natural chidlbirth: http://www.youtube.com/watch?v=T83WoXuVhjs

  12. avatar
    Kim RMT
    February 23rd, 2011 at 08:22 | #12

    @Walker Karraa, MFA, MA, CD
    I don’t know about Heidi’s thoughts, but the way that I look at things is that I cannot judge or decide for a mother-to-be what is right for her. All I can do is give her the information and tools that she needs to make a decision that is right for HER, and support her when she has made it.
    In the case of a woman who has been abused in her past and is terrified of pain, I personally would not push too hard against epidurals, but I would still work on pain management techniques and comfort in using them. I would also work on helping her experience similar sensations in a controlled environment (I do a timed “contraction” with an ice cube in hand). The biggest work in this case would be to earn her trust and let her feel SAFE in whatever decision she makes. That feeling of safety may allow her to try out some of the techniques before asking for the epidural.

    I love what Penny Simpkin has said (taken from a video she has posted):
    “There is a difference between pain and suffering. Pain is a physical sensation, and it’s an unpleasant one. It’s sometimes associated with damage, but it can be associated with… physical exertion, muscular exertion, etc.
    Suffering is a sense of being overwhelmed, of being helpless, of being out of control. You can have suffering without any pain… People can have emotional suffering when they’re deprived of something, when they lose a loved one. They have no physical sensation that causes it, but it’s emotional suffering.
    In childbirth, yes, many women have suffered in childbirth, and it’s because they’re not kindly treated, they’re not respected, they don’t know anything they can do for themselves… they feel unloved, so they feel alone. That can turn the pain into suffering.”

  13. February 23rd, 2011 at 08:57 | #13

    @ Kim and Walker:

    I’m so glad to see this dialogue unfolding and happily insert that Penny’s second post on childbirth-related PTSD will be available this coming Monday in which she addresses this exact question: are pain and suffering the same thing and, if not, how do we reduce a woman’s chance of suffering during birth even when an epidural is present?

    Do stay tuned and, in the mean time, keep the dialogue alive!

  14. February 23rd, 2011 at 16:46 | #14

    @Walker Karraa, MFA, MA, CD
    “I would like to ask what your thoughts are regarding the use of epidurals for women with previous history of sexual trauma. I often work with women who feel pressured by doulas, childbirth educators, and friends, into not getting an epidural, but whose previous history leads to incredibly difficult, if not exacerbating anxiety regarding pain. Any thoughts would be appreciated.”

    I am well aware that some women with a history of sexual abuse or assault may want to plan on having an epidural. The same is true of some women with a prior traumatic birth. As I hope the reprint of my article makes clear, I take my stand on women making informed choices based on a nuanced knowledge of the pros and cons of all their options (which, of course, means they have to have some other than an epidural). Once they have that, I trust that women will be able to make decisions that best meet their needs, and I deplore the arrogance of those who think they know better what is best for a woman than the woman herself.

  15. February 23rd, 2011 at 21:08 | #15

    Thank you! You speak so well to it with this: “Once they have that, I trust that women will be able to make decisions that best meet their needs, and I deplore the arrogance of those who think they know better what is best for a woman than the woman herself.” And you give me hope that there are amazing advocates like you out there bringing information to all women. Fantastic response, thank you

    I look forward to hearing what Penny offers as well regarding how to help women with this decisions.

  16. avatar
    Katrina
    February 24th, 2011 at 10:06 | #16

    @Ann Cowlin
    Ann, thank you, sincerely, for the questions you posed!!! As an L&D nurse with 3 kids, I have mamas looking at me like I have 3 heads, too, when they hear I’ve never had an epidural! Now, I will agree that sometimes they are useful, and, dare I say, even necessary at times, HOWEVER, I take exception when women flat out tell me they don’t want to feel ANYTHING! Aren’t your children worth the discomforts of pregnancy and yes, even the pain of labor and delivery?? I know mine are! Of course, we’re not allowed to voice that, for fear of upsetting the patient/family, and damaging our Press Ganey scores, because that’s what bringing a child into this world is all about, don’t ya know?

  17. February 26th, 2011 at 12:12 | #17

    Wow, Katrina. Equating a woman’s choice of pain management with her commitment or love of her children is downright disturbing. I respect your personal sense of pride regarding your births, but as long as we hold women in our personal judgments of right and wrong, good and bad, we are part of the problem.

    How can we continue to promote the idea that their is pride in another’s version of what we should do with our bodies?

    That kind of thinking is patriarchal in that we hold the power over women to tell them what to do with their bodies.

    To me, your thinking sheds light on how far we haven’t come, baby. Don’t ya know?

  18. March 3rd, 2011 at 23:12 | #18

    @ceridwen morris
    Hi Ceridwen: With regard to your statment: “I continue to think his website is misleading and his proposal that we have epidurals for after pains is just not logical.” I have just noticed that two moms described their experience with severe afterpains on your Babble.com blog. I posted an extensive comment there. In brief: Not only are epidurals for afterpains logical, they work wonderfully! Please keep an open mind. It’s the only way we (humankind) can advance.

  19. March 3rd, 2011 at 23:18 | #19

    @Walker Karraa, MFA, MA, CD
    Hi Walker Karraa: You wrote: “I say Grantly Dick Read is as much to blame as Dr. Grant.” I don’t believe anyone has ever before used me in the same sentence as Grantly Dick-Read – and I certianly hope no one ever does so again! :-)

  20. March 3rd, 2011 at 23:38 | #20

    Henci Goer wrote:
    “Dr. Grant says that according to his analysis of the medical studies, epidurals:

    •Can speed up labor
    This may be true for some women but not in general. Meta-analysis, a technique for pooling data from multiple trials, finds that epidurals slow labor and increase the need for strengthening contractions with oxytocin.
    •Don’t increase the need for cesarean
    True, but this is because other factors outweigh epidurals. In a nutshell, if a woman has a care provider who tries to minimize use of cesarean, she is at low risk of surgical delivery regardless of whether she has an epidural, and if her care provider resorts to cesareans liberally, she is at high risk, again, regardless of whether she has an epidural.
    •May reduce the likelihood of postpartum depression
    Studies of what makes for a satisfying birth experience consistently find that quality of supportive care is the key factor, and pain management only enters the picture when the woman’s pain relief expectations are not met.•Can help with breastfeeding
    Epidurals are associated with breastfeeding difficulties, although these can be overcome with good support. Dr. Grant, though, is actually proposing epidural anesthesia after the birth, to relieve postpartum discomforts that he believes interfere with breastfeeding. Few women, however, would need anything more than an ice pack and maybe some over-the-counter medication for cramps after vaginal birth especially if they have not had instrumental delivery or an episiotomy. As for post-surgical women, I would think that impairing mobility would increase risk of deep venous clots and that conventional pain relief methods are deemed adequate for every other type of surgery.

    I was interested to read Ms. Goer’s comments, although I have no indication that she read my book, “Epidural Without Guilt: Childbirth Without Pain.” I must say, though, there is a lot of common ground here! Ms. Goer agrees with me that epidurals can speed up labor for some women. Ms. Goer also agrees with me that epidurals don’t increase the need for cesarean. And Ms. Goer does not dispute that epidurals may reduce the likelihood of postpartum depression, hence we are in agreement again! There is an issue where Ms. Goer and I really disagree, though. Her fourth point. The one about breast-feeding. I have seen epidurals really help with breast-feeding. That’s because afterpains can be excruciating – even worse than labor (especially for moms who’ve had many babies). But don’t take it from just me – two moms recently commented about their own experience with severe afterpains on Babble.com. Of course, most moms don’t experience severe afterpains, but for those that do, an epidural can be the difference between nursing their newborn or refusing to do so. And don’t let that “impairing mobility” thing or “deep venous clots” bother you. Neither apply to the ultra-low dose walking epidurals I use for my post partum women. As I mentioned (except for my position that epidurals can actually encourage breast-feeding) I think Ms. Goer and I agree on a lot of things!

  21. March 4th, 2011 at 09:40 | #21

    @ all: regarding the point about whether or not epidurals lead to cesarean births…check out Dr. Michael Klein’s final post in his series about epidurals. In a nut shell, it comes down to when the epidural is (or isn’t) placed: inserting in early labor has been shown to increase c-section birth outcomes (see references attached to Dr. Klein’s post series). Placed after the woman has merged into active labor reduces this risk. As doctor Klein also aptly points out, (echoed in this blog post, as well) another huge influence on c-section rate (epidural or no) is the provider with whom the woman is birthing: does she/he have a high c-section rate, or low?
    For the first two segments of Dr, Klein’s post, go here and here

  22. March 4th, 2011 at 16:27 | #22

    WHOA NELLIE !!!!!!!!!!!!!!
    Readers beware: Despite Dr. Klein’s post that epidurals given early in labor increase the risk of cesareans, it’s important to realize that the most recent data do not support this conclusion. If you’re interested, you can read my response on “Science & Sensibility” to his post. And if you’re really interested in looking into this matter (which I would hope we could all move beyond as we discuss the various reasons to use or avoid epidurals for childbirth), you can read the original research papers from 2005, 2006 and 2009. The most recent paper prospectively studied nearly 13,000 women and found that giving the epidural as early as ONE centimeter dilation did not increase the chance of cesarean (or length of labor, for that matter). The evidence is quite strong. Epidurals do NOT cause an increase in the rate of cesarean, even when given early in labor. If someone doesn’t want an epidural, that’s their choice of course, and I fully support them in their right to do whatever they want – but if they’re trying to decide what to do, they should have the FACTS – facts that are based on science – and current science, at that.

  23. avatar
    Michael Klein
    March 4th, 2011 at 22:31 | #23

    @Gilbert J. Grant, MD
    Read my comments on the three papers that Dr. Grant uses to support his claim that early epidurals do not increase the Cesarean section rate. What they have in common is that they either are nor really about early epidurals (Wong) or they take place in settings that in no way reflect our usual high Cesarean environments (Ohel) or in industrialized settings where birth is even more intrusive than is the case in North America (Wang from China). The latter two studies are meaningful and useful for the settings in which they take place (internally valid) but not for our usual North American environments (lack external validity). This is epidemiology 101. Randomized controlled trials perfectly reflect the conditions in which they take place. If those are your conditions, they speak to you. If not, they do not.
    Michael

  24. March 6th, 2011 at 00:56 | #24

    Not claiming anything. Simply stating some facts.
    It’s interesting that Dr. Klein dismisses the four most recent randomized prospective studies that show early epidural (or spinal) anesthesia DO NOT increase the cesarean section rate. We are to ignore Ohel’s “excellent” study because it was conducted in a setting where cesarean rates are much too low compared to North America. We are to ignore Wong’s study because combined spinal – epidural analgesia was used (the spinal part prior to 4 cm dilated). And Wong’s second study (2009) is not even mentioned. This second study, done in women with induced labors had essentially the same findings as the first Wong study in women in spontaneous labor. I suppose we should ignore this one also because the combined spinal-epidural technique was used. While it is true that there are some differences between combined spinal-epidurals and plain epidurals, both yield very similar results, namely, profound pain relief and decrease maternal catecholamine levels. Plain epidurals and combined spinal-epidurals are used interchangeably by many anesthesiologists (I explain these techniques in my book “Epidural Without Guilt: Childbirth Without Pain”. Finally, we are told to ignore Wang’s study ( “one of the largest studies ever conducted in obstetrics”) because it was done in China where the setting is “so industrialized and interventive.” I live in New York. Our hospital has a cesarean rate of 29%. And I do believe that New York and the rest of the U.S. is industrialized. I suppose that the 29% cesarean rate means that we are “interventive” as well. So why exactly does this huge study of nearly 13,000 women not apply to the women who deliver at my hospital? So, to summarize: four recent prospective randomized studies that show that early epidurals (or combined spinal – epidurals in the case of Wongs two studies) DO NOT increase the rate of cesarean but they should be ignored. And we should continue to think that early epidurals lead to a greater chance of cesarean. What the reality? The reality is that there is NO CAUSITIVE LINK between early epidurals (or early combine spinal-epidurals) and cesareans. And ignoring well-designed prospective randomized studies, and telling women that there is a risk of getting state-of-the-art analgesia early in labor is unfair. Women should not be denied pain relief on the basis of their cervical dilation. If they are in pain, and they want the pain relieved – completely relieved – they should understand that they may choose an epidural or a spinal without concern that it will increase their risk of cesarean. Lastly, here’s a quick question for Dr. Klein: Is he aware of ANY prospective, randomized controlled trial that showed what he claims to be true, namely, that early epidurals cause an increased incidence of cesareans? Just wondering.

  25. avatar
    Gilbert J. Grant, MD
    March 8th, 2011 at 23:51 | #25

    Hi Andrea: I just now noticed your post. We’ve been using “walking” epidurals at my hospital for about 20 years now. Although I must tell you most patients don’t walk much – but that’s another story. They do have the ability to do so and certainly to walk to the bathroom and to get into various positions during labor and delivery. I agree with you that using low-dose epidurals is a good thing. I would hope that everyone would use them. Dr. Klein was specifically discussing the issue of the use of early versus late epidurals and the effect on the cesarean rate. Those studies are not unethical to do, and in fact over the past few years, such studies have been done – including one involving nearly 13,000 women. And those studies showed that epidurals and combined epidural-spinals DO NOT increase the cesarean rate. My challenge was to tell me about a study of early versus late epidurals that shows it DID increase the cesarean rate. But there isn’t such a study, because early epidurals DO NOT increase the cesarean rate. There are some interesting studies that look at the general question of epidural or no epidural on cesarean rate (in other words, forgetting the early versus late in labor question). A whole bunch of studies have been done where an institution was looked at BEFORE and AFTER epidural use either became available or increased dramatically. I review one of these studies in my book, which was done at Trippler Army Hospital in Hawaii. There are at least nine others. A total of nearly 40,000 deliveries. And the findings in every case are similar: the institution or dramatic increase in epidural availability was not associated with an increase in the rate of cesarean section. The issue has been decided – except, of course that facts don’t mean a whole lot to people who would rather ignore them. Beware of “observational data.” It is very weak. For example, I can tell you about many obstetricians who swear up and down that in “Mrs. So-and-so, we put in an epidural and her labor took off.” Does that mean any more than the stories about other moms-to-be who had their labors essentially halted by epidurals. All of this is called anecdotal evidence, and, scientifically speaking, it is very weak. We need properly conducted trials to reach meaningful conclusions. With regard to epidurals causing cesareans, the trial are done, and it’s clear that there is no causative link between epidurals and cesareans. I’m not saying everyone needs an epidural. But it’s really unfair to distort the data so that someone considering getting one is given the impression that if she gets an epidural, her chances of cesarean increase. Its simply not true.

  26. March 9th, 2011 at 00:58 | #26

    I find it puzzling that you chide the use of anecdotal data when your assertion that epidurals can speed up labor is also anecdotal. As I wrote in my blog post, the actual evidence is that epidurals slow labor. (By the way, one reason why epidurals may appear to speed up labor is that women are likely to request an epidural after the shift into active labor when contractions become more intense or in conjunction with starting an oxytocin drip.) Moreover, your assertion that postpartum epidurals enhance breastfeeding does not even reach the level of anecdote. It is purely speculative. Nor am I aware of any research evidence backing your claim of a link between epidural use and decreased risk of postpartum depression. Again, as I wrote in my blog post, pain relief only affects satisfaction with the birth experience when expectations are not met. (This cuts both ways: A woman who wanted an unmedicated birth and didn’t achieve her goal is likely to feel disappointed, and a woman who wanted an epidural and didn’t get one is equally likely to be dissatisfied.) Logically, if a woman who was satisfied with her birth develops depression, the use or not of epidural anesthesia doesn’t come into it.

    Finally, as my blog post also makes clear, there is no controversy over the fact that epidurals increase the likelihood of instrumental vaginal delivery, and for that reason, they increase the risk of anal sphincter tears, a serious complication. They are also associated with a list of unpleasant side-effects and other potential complications and the need for interventions such as continuous monitoring, labor augmentation, and bladder catheterization that have their own complications. On rare occasions, they cause a life-threatening adverse event. Women have the right to know about these possibilities. Whatever our disagreements, I hope we agree that women have the right to make an informed decision, which means understanding the benefits versus harms of all their options.

    (FYI: There is a link to my sources at the bottom of my post.)

  27. avatar
    Gilbert J. Grant, MD
    March 9th, 2011 at 14:03 | #27

    Ms. Goer: My “assertion” that epidurals speed up labor is not anecdotal. Three recent randomized, prospective studies (Wong 2005, Ohel 2006, Wong 2009) found that early (I.e., prior to 4 cm) neuraxial analgesia (epidurals / combined spinals-epidurals) sped up labor compared to neuraxial analgesia that was instituted later (i.e., after 4 cm dilation).The fourth study of this issue (Wang 2009) involving nearly 13,000 women did not find a difference in labor duration. But it’s kinda silly to argue about this point, isn’t it? Let’s assume for a moment that we ignore these data and take the disproven position that early epidurals actually do slow labor. After nine months of pregnancy, what’s so important about another few minutes? Especially for a woman who s not experiencing excruciating pain, but rather resting comfortably and feeling only a tightening sensation or a sensation of pressure as the baby descends? Do you think most women really care? Is there any evidence that a few more minutes of labor is bad for the baby? C’mon, now. It’s silly to focus on this. With regard to postpartum epidurals encouraging breast-feeding, I never claimed to have prospective randomized data, but please Ms. Goer, it is dismissive of you to say that my experience with this “does not even reach the level of anecdote.” I have cared for women who I have helped by providing postpartum epidural analgesia, and they have specifically told me that it helped them to breast-feed their newborns. By definition, that is anecdotal! And it’s why I continue to offer this option to women who have a history of severe after-pains, poorly relieved even by narcotics, with previous deliveries. Just because you’ve never witnessed something, or are not aware of it, doesn’t mean it’s not valid. And it’s certainly no reason to denigrate it, or close your mind to it. Don’t we share a common goal here of encouraging breastfeeding for ALL women? Even those who have had traumatically painful experiences with it in the past? Regarding pain and postpartum depression, you state “pain relief only affects satisfaction with the birth experience when expectations are not met.” While meeting expectations is certainly important, the likelihood of getting postpartum depression, as well as post-traumatic stress disorder, a very serious psychiatric condition affecting 1 to 2 % of postpartum women in its full-blown form according to the most recent data, may be increased by experiencing a traumatic, painful childbirth. More work needs to be done on this, without question, but although data are accumulating, very few people seem to be aware of it, including, for example, you. I provide some references in my book – even a recent reference that looks at unrelieved pain during the first 36 hours AFTER delivery (Eisenach 2008). Those investigators found that pain after delivery – regardless if it was vaginal or cesarean – was an independent risk factor for developing postpartum depression (3-fold as likely). You may want to make yourself more aware of these data. They have significant implications for parturients. I agree with you 110 percent that women need to understand the risks and benefits of all procedures so that they can make an informed decision. Of course there are risks to getting an epidural. No one is denying that fact. But what I have done in my book is something that isn’t really discussed much, namely the risks of NOT getting an epidural and the risks of unrelieved pain for the mother and the baby. Understanding these risks as well are necessary for a woman to make a truly informed decision about what type of pain relief, if any, she may want for her delivery and postpartum period.

  28. avatar
    Kim RMT
    July 4th, 2011 at 15:00 | #28

    Dr. Grant, while I am not going to argue your statistics, I will put forward the idea of birth from my point of view – that of the Doula, and share some of my concerns:
    1) Movement during labour is very important to encouraging the baby’s decent down the birth canal. While you might provide “walking epidurals” in your clinic, I haven’t heard of many other clinics offering them – perhaps the discussion should even be changed to discussing the effects of a “light” epidural vs. a “regular” or “full” epidural? Regardless, in my area (New Brunswick, Canada), the “light” epidurals are not offered, and a woman is confined to bed once a “regular” epidural is administered. This not only limits movement during labour, but also limits most of the birthing positions to either the lithotomy position or a side-lying position and can lengthen labour and delivery by doing so.
    2) While I do encourage using natural methods for labour management, I also see epidurals as one of many “tools” I have for helping women through their labour and child-birth. There are certainly times when it is appropriate – my point is that women are not always being given a choice, and are being told that they **are GOING to have one**, especially if they are having an induced labour. In many ways, I have seen that there is a growing assumption that women in labour are going to have epidurals, and this is not a wise assumption to have – there ARE side-effects and risks to epidurals, and it is NOT every woman’s choice to have one. When medical care providers take that choice away – it is very frightening to see, and a step backward in clinical care!
    3) Something that is often over-looked is that epidurals don’t always work, or don’t always work fully! Part of that is due to the skill of the anesthesiologist, but also due to a woman’s particular physiology. Women can be left with only one size “frozen”, or have only partial blockage happening. Some women just do not “freeze”. And, yet, this is a form of pain relief that is often considered the “be-all” and “end-all” of labour management! If this is what the hospitals rely on, what will they do when it doesn’t work (or doesn’t work fully)? Also, there is the issue of availability of the anesthesiologists. Will there then be some who are devoted purely to administering epidurals? What happens if they are busy – what will the woman do then? Is this an appropriate place to put our health-care dollars?
    4) Your comments “After nine months of pregnancy, what’s so important about another few minutes? Especially for a woman who’s not experiencing excruciating pain, but rather resting comfortably and feeling only a tightening sensation or a sensation of pressure as the baby descends? Do you think most women really care?” are misplaced. It’s not the picturesque image of a woman relaxed and reclining in bed while her uterus is “doing it’s work” that is the problem. It is the physicians who are monitoring her and declaring that she is not “progressing fast enough” that is! A longer labour (“longer” meaning by more than just a few minutes!) can put a woman at a higher risk of use of Pitocin (which DOES increase your risk of a C-section), or other interventions. Also, while labour can be painful, I do object to the idea that every woman in labour is in “excruciating pain” – or, at least, not when she has been properly prepared, and has appropriate, trained support! (And, before you say it, I’m not exaggerating with the “every woman in labour” statement if the epidural rates are 90% and rising!)

    In the end, certainly, epidurals have their place. I’m sure that there ARE women for whom it is entirely appropriate, both in labour and post-natally. I just believe it is downright dangerous to make it such a common occurrence and assumption as it is becoming. Dangerous to not only our health, but our empowerment as women, and to the ability to make choices for ourselves. Besides, I personally believe that birth is intended to be experienced. This is a day that all mothers remember! I believe that if we numb it away, and make it “just another medical procedure”, then we run the risk of reducing our awareness of the preciousness of life. Childbirth is a life-altering event – a rite-of-passage. Yes, it is a challenge, and, no, I am not saying that we need to be martyrs, but it is something that we CAN pass through successfully, and be proud of that success when we look at the new life that we created! After all, marathon runners do not look to numb themselves before a race! We would laugh at the idea! Instead, we applaud their perseverance and tenacity, and celebrate their victory when they cross the finish line! Shouldn’t we value childbirth at least as much?

  29. avatar
    Larissa
    December 13th, 2011 at 22:20 | #29

    Epidurals have their place in complicated births but we need to give women back the real education that their bodies and babies were designed to do this! Give them back the chance to trust birth and intervene when nature needs a little help. Women experiencing pain is not a shameful thing and as a doula I have heard more women feeling robbed of an experience from an epidural rather than being thankful for one. Doctors used to recommend smoking according to scientific evidence as well… http://www.youtube.com/watch?v=gCMzjJjuxQI Scientific based evidence doesn’t mean it’s right for you. Trust your bodies abilities to give birth, it’s a timeless ritual sacred to women….lets give it back.

  1. February 21st, 2011 at 09:26 | #1
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