A delicate dance between its positive role and unwanted side effects

This is the beginning of a three-part series of posts from family practice physician, pediatrician , neonatologist and Senior Scientist for the Centre for Developmental Neuroscience and Child Health and the Family Research Institute, Dr. Michael Klein, who will share this thoughts and analysis with us regarding epidural analgesia…

A short history of epidural analgesia
It was not until the 1960s and 1970s that epidural analgesia became widely available. Prior to that, anaesthesia services dedicated to the provision of epidural analgesia did not exist. By the 1990s, obstetrical anaesthesia services dedicated to maternity care became common in developed countries.

Prior to the ready availability of epidural analgesia in labour and delivery departments, maternity nurses used their skills to reassure, massage, breathe with the woman through contractions, and employ a range of other methods to handle labour pain. But today, the shortage of staff and the institutional demands on nurses make these skills relatively unavailable. In addition, the education of nurses has taken a more technical turn; the ‘old-fashioned’ skills of hands-on nursing has been replaced, in many educational programs, by teaching technical skills related equipment and medical interventions.

It became clear that to make epidural analgesia reliably available, a dedicated anaesthetic staff had to develop. Once such staffs were in place, there was great pressure to keep them busy. After epidurals became more available, a debate ensued, and goes on to this day, about whether withholding an epidural was interfering with a woman’s autonomy. This discussion did not seem to take into consideration that women might not select an epidural if they knew more precisely how long severe pain would last, or if they understood the benefits and problems associated with epidural use, or if staff were trained in a variety of other effective techniques to assist with the pain of labour. In fact, many women are directly or indirectly pressured into accepting epidurals.

The implications of epidural use
Although it first seemed that epidural analgesia freed up nurses to care for more than one woman at a time, in fact, it soon became clear that the labour and delivery nurse’s time was consumed by the technical requirements of safely managing the epidural and the rest of the technical requirements of her job, leaving little time for hands-on nursing support.(1) A woman who has an epidural requires an intravenous line and continuous electronic fetal monitoring to measure both the fetal heartbeat and the uterine contraction pattern. Because labour usually slows after an epidural, the woman typically requires synthetic oxytocin (Pitocin) augmentation to replace her natural oxytocin production, which is inhibited by the epidural itself. Pitocin can cause painful and very strong contractions: therefore its use requires detailed charting and monitoring for the potential complications of the epidural.

Usually after the introduction of an epidural, a woman has to remain in bed because she cannot feel her legs and she is attached to many wires and lines, so this limits her ability to walk or change position. ‘Walking epidurals’ and telemetry are available only in rare settings and by particular anaesthesiologists. Tethered to intravenous lines and other lines (e.g. urinary catheter, blood pressure cuff,  fetal monitor and the tocometer) and unable to walk, it is almost impossible for the woman to use gravity and different positions to help progress her labour.

The development of new pain management techniques
Prior to the availability of epidural analgesia, the childbirth education movement utilized a variety of techniques that were physiologically and psychologically helpful to reduce pain, such as breathing and imagery. These methods began to take hold in the culture in the 1950s and 1960s but today are less prominent in many childbirth education classes. Some classes are more focused on teaching women compliance with particular hospital technological methods and approaches, routines and policies, rather than on teaching women coping skills.

In the late 1970s and early 1980s, the first studies appeared, showing the value of continuous emotional and physical support by a caring, trained and knowledgeable woman, whose responsibility was to focus solely on the labouring woman rather than on the institution or equipment – the doula. Backed by randomized studies,(2-4) it has become apparent that this emotional and physical continuous support from a doula gives a woman more confidence and ability to work with her labour. All studies to date have demonstrated that hospital-based nurses cannot function as doulas,(5, 6) even if those nurses are midwifery-trained. It is not the fact of being either a midwife or a nurse that matters, but the fact that when these care providers areemployed by the hospital, their primary allegiance is to the institution, and they areprofessionally responsible for the conduct of the labour and the safety of both mother and fetus. A doula who is employed by the woman is responsible only to her. Autonomous midwives in the Canadian context are strongly supportive of doulas, with whom they frequently work in collaboration.

Pain moderation by transcutaneous nerve stimulation (TNS) or intradermal water injections can be very helpful, especially in the earlier stages of labour. Other non-pharmacological methods like water baths or showers or movement, including the use of birth balls, are also helpful for many women who find that partial pain relief is sufficient to help them through contractions. Doula care provides a complementary approach which can reduce the need for an epidural or delay epidural usage until the active phase of labour, when some of the negative effects of epidural analgesia are reduced. In particular, during her labour, doula care and non-pharmacological approaches allow the mother more opportunity to produce her own oxytocin. Natural oxytocin has some important effects: it is the anti-stress hormone, and helps contractions to be more productive; it is also the ‘love hormone’ that later goes on to enhance the bonding process following the baby’s birth—an effect suppressed by synthetic oxytocin, little of which enters the brain of either mother or fetus.

Is epidural analgesia the best form of pain relief?
Epidural analgesiais a very effective form of pain relief, meaning that compared to a variety of other pharmacological and non-pharmacological methods, it provides generally consistent pain reduction. If there were no problems associated with epidural analgesia, almost everybody would want it. Unfortunately, though, associated with its use there are various undesieable effects, including:

  • longer first stage labours
  • longer second stage labours
  • increased incidence of maternal fever directly caused by the epidural, which often leads to the use of antibiotics in both the labouring woman and her newborn
  • increased rates of operative vaginal delivery (forceps and vacuum)
  • increased perineal trauma with and without instrumental births – including severe tears into the rectum (3rd and 4th degree tears).
  • a variety of complications such as a placement of an epidural too high on the spine (leading to breathing problems).
  • failure of the epidural to provide any pain relief, or insufficient pain relief—requiring the continued use of other methods of pain relief
  • increased need for a bladder catheter
  • maternal hypotension leading to worrying fetal heart rate changes
  • an increase in the likelihood of the need for a cesarean section – this last complication being the subject of great debate, which will be discussed further

Of course, some of these problems may occur whether the epidural was or was not truly needed. And when an epidural is truly needed for pain relief or to solve a specific problem, it can dramatically change a situation for the better and can improve outcome. It is only when epidurals are used routinely, and especially very early in labour that these complications are more likely to occur.

Dr. Klein’s next post will take a look at the research on epidurals and discuss the risks and benefits of this pain relief technology.
All references for this post series can be found here: References _ michael klein post.

Posted By:  Michael C. Klein, MD, CCFP, FAAP(Neonatal-Perinatal),FCFP, ABFP
Emeritus Professor of Family Practice and Pediatrics University of British Columbia
Senior Scientist Emeritus
Centre Developmental Neuroscience and Child Health
Child and Family Research Institute
4500 Oak Street
Vancouver, V6H 3N1
Tel: 604-875-2000 ext 5078
Fax: 604-875-3569
Email: mklein@interchange.ubc.ca


Epidural Analgesia—a delicate dance between its positive role and unwanted side effects (Part One)

January 4, 2012 07:00 AM by Meggan
Hello- I just wanted to note that the references for these articles do not work. I'm very interested in looking at the articles and would appreciate an active link. Thanks!

Epidural Analgesia?a delicate dance between its positive role and unwanted side effects (Part One)

November 4, 2013 07:00 AM by R
I think it is disappointing when in an article like this, the pain of childbirth - which the majority of women feel - is minimized or explained as primarily a result of "fears". Whoever has a pain-free or low-pain labor - more power to you! Be happy that you are so lucky. For most women, that is not the case. Throughout history, women feared labor because it was dangerous and very painful. We are not the first generation to experiment with "positive thoughts" and hypnosis. If these approaches would work so well, we'd know it - no one would need an epidural. However, they don't. Some lucky women can get by with natural methods, some cannot, and some choose not to. Personally, I had two home births, one of them with excellent support by two midwives and a doula. I am young and healthy, watched positive birth movies and wasn't scared (the first time). Both times, my labor pain was absolutely excruciating. Yes, I made it through - what else should I have done? But breathing to relieve the pain...? Come on. Try that with your next root canal treatment and tell me how well it worked for you. Yes, you'll get through it if you have to - in fact, people did for centuries (just like they got through amputations and other horribly painful procedures without anesthesia). But it sure as hell doesn't take the pain away. During my two home births, breathing, massage and mentally preparing myself for the next contraction helped me to not literally go crazy or become hysterical from the pain. That was it. It didn't relieve the pain one bit. So, yes, I "made it". Yay. GO, R. But what for....?? Who are we trying to impress? (Like one of the previous posters pointed out, modern epidurals are extremely safe, they do not appear to interfere with labor and due to the medication being administered into the epidural space and not your bloodstream, only very tiny amounts ever make it to the baby. There is usually no medical reason to forgo an epidural IF you want one - just like there is usually no medical reason to forgo anesthesia for root canal, or surgery or other painful procedures.) I absolutely agree with the argument that there is no other situation where extreme pain is deemed acceptable by health care providers, or where it is insinuated that, really, you should be willing to bear the pain (as babynurse and others on this thread did). Why is that? Are doctors and nurses "sorry" that dental patients ask for pain relief as soon as they can feel the drill, or that they "feel as though there should be no pain associated with dental treatments"? No. It's only women who are, according to some, supposed to bite down and bear it. Just to be clear - I am not opposed to anybody laboring without pain relief. Why should I? (I myself did it twice.) Everybody should have the option to labor the way they want to, including good non-medical labor support. What I'm opposed to is suggesting that women SHOULD labor without pain relief. Yes, labor is a natural process, but nature doesn't care for my pain level. All that matters to "nature" - ie, evolution - is if I successfully procreate. And I did - in pain, just like billions of women before me. However, as opposed to billions of women before me, I am lucky enough to live in a time and place where effective and extremely safe pain relief is available. It is absolutely ok to take advantage of that, or to desire a child birth that is (hopefully) truly pain free.

Epidural Analgesia—a delicate dance between its positive role and unwanted side effects (Part One)

June 4, 2014 07:00 AM by 10 Things to Know Before Getting an Epidural
[…] routinely or without reasonable cause; the biological effects on both mother and baby areámedically documented. Here is a brief […]

Mmm, except many of those wome

October 14, 2015 07:00 AM by Adel
Mmm, except many of those women would have torn ANYWAY - and that without pain relief. Have ANY idea what it is like for a woman to have a forceps delivery, torn apart from the inside, WITHOUT pain relief? Not only can there be 3rd / 4th degree tears for the rectum, the entire "foundation" area suffers traumatic injury. Which is uncontrolled, by the way... So in that sense, a C-section is much safer. Sure, the risk for epidurals in terms of tearing and so forth are statistically significant. But it is measured in terms of relative risk. I expect that many women would regard a 7% chance of instrumental intervention with an epidural, as opposed to a 5% chance of instrumental intervention without one, as an acceptable risk. (40% relative risk) The same goes for longer labour. Many hospitals refuse to perform epidurals during the first stage of labour - as performing them then is primarily what increases their risk. If faced with a mean difference of 5 MINUTES longer (second stage) labour (considering that you are in labour for approximately 12 hours or so), do you think women are really going to care? THE PROBLEM IS THAT ARTICLES LIKE THESE ONLY HIGHLIGHT THE DANGERS OF THE EPIDURAL IN ABSOLUTE TERMS, INSTEAD OF EXPLAINING THEIR LIKELIHOOD AND THEIR POTENTIAL IMPACT. I would also like to know where people on this comment thread got the statistic that epidurals are likely to cause foetal distress in 10% of cases. I very much doubt that it is accurate. Perhaps the author would like to enlighten them. In terms of the increased risk, this is not necessarily CAUSED by the epidural, there are many other contributing factors. Correlation does not measure cause and effect! (Called the "lurking variable") Especially with first births, women don't know what "good" pain and "bad" pain is - they are just in incredible pain. Which is when you start shouting for the epidural. The studies look at foetal positions just prior to birth, not foetal positions just prior to the epidural. It is thus possible that women whose babies are in the wrong position, or experiencing foetal distress for some other reason, are more likely to demand an epidural. Genetic factors are a major contributing factor to tearing, even in births which seem like an "acceptable" risk for normal birth. An epidural cannot be administered while pushing. Choosing an epidural if you are going to need an instrumental delivery anyway - that seems like an absolute no-brainer to me, but perhaps not to those supporters of "good pain". These studies don't answer the question - do epidurals CAUSE all these problems, or are women who are more likely to suffer from them more likely to ask for epidurals? Even births for the same woman are not the same. So, you will never really be able to tell. Simple solution: If you don't want an epidural, just say no :) Leave the women who need them (or want them) alone. Their birth choices are really none of anybody else's business.

@Adel I.E. 1. Women may not re

October 15, 2015 07:00 AM by Adel
@Adel I.E. 1. Women may not regard a percentage which is "statistically" significant, as significant to their personal decision-making process. 2. You are more likely to need an instrumental intervention just because you need it (5% prevalence in US) than

between its positive role

February 8, 2016 07:00 AM by Epidurals in Labor | Lullaby Birth Services, LLC
between its positive role and unwanted side effectsâ?Ł for the website Science and Sensibility (Part One, Part Two, Part Three).?  He writes about his experience working at the Department of Family [?]

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