I would like to avoid an epidural, please don’t offer me one

Epidural use for pain management in labor has become standard in the United States, with the number of women selecting this option having tripled since the 1980s. In 2011, the CDC reported that 61% of women delivering vaginally had an epidural, however in individual hospitals, that rate may exceed 90%.¹ During an epidural, a small catheter is threaded into the epidural space, an area between the bones of the spine and the dura mater that surrounds the spinal cord. Two types of medications, a local anesthetic and a narcotic, are then infused into the epidural space continuously throughout the labor until after delivery, providing pain relief, as well as some degree of numbness and immobility, from the breast line down. Overall, epidurals provide effective pain management for the majority of women, with 88% of women who receive epidurals reporting good pain relief. It also is one of the safest forms of pain relief from the standpoint of the both the baby and mother. Rates of permanent maternal injury related to any form of spinal or neuraxial block is low, at 1.2 per 100,000, while the rate specifically with an epidural is 0.6 in 100,000. While all medications cross the placenta to some degree, the amount of medication that enters maternal circulation and thus reaches the baby is low and, when compared to IV narcotics for pain relief in labor, babies do not demonstrate a suppressed breathing response, have higher APGAR scores, and have a lower likelihood of needing medications to reverse the narcotic effect.²

Given the efficacy of an epidural and the relative safety, many people are incredulous that any woman would want to give birth without one. Common responses women planning to labor unmedicated hear from their family, friends, nurses, and doctors alike are:

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  “You wouldn’t have a tooth pulled without anesthesia, why would you have a baby without it?”

  
  
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  “Don’t be a hero, having an epidural doesn’t make you any less of a mother.”

  
  
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  “You say that now, but just wait until labor starts! They don’t call it labor for nothing.”

  
  
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  “Are you crazy?”

However, like any other medication or medical procedure, epidurals are not side effect or complication free. Many women would simply like to avoid these possible issues if they are able to manage their labor utilizing other tools, which is far from “crazy”; it is very sensible.

Longer Labors and Increased Chance of Operative Vaginal Delivery

In most of the studies to date, epidurals have been shown to both prolong labor and increase the likelihood of a woman needing instrumentation, either vacuum or forceps, to achieve a vaginal delivery. The studies examining epidurals are numerous and vary greatly in their precise findings, but the largest review on the topic found that epidurals are associated with an increase in the first stage of labor of anywhere from 1 to 4 hours and an increase in the second stage of labor of up to 1 hour. The same review, involving over 8000 women, found that the risk of an operative delivery was 5% greater in patients who received epidurals.³

There are several explanations offered for why these variations may exist. One hypothesis is that the large quantities of fluid necessitated by an epidural dilute the hormone concentrations in the blood which are generating the strength and consistency of uterine contractions. While not demonstrated by a study, nearly every provider can describe the phenomenon where a patient enters the hospital with a strong, consistent labor pattern, receives an epidural, and inexplicably her contraction pattern stops. Another theory about the longer labors seen with epidurals, particularly in early epidurals given before full descent of the baby in the pelvis occurs, is that epidural-generated muscle relaxation promotes an inappropriate fetal head extension and increases the rate of malpositions, such as occiput posterior or sunny-side up babies. While not statistically significant according to the Cochrane Review, greater numbers of women with epidurals do have malpositioned or occiput posterior babies (18% vs. 13%). When this review is further examined and studies excluded where more than 10% of women grouped in the “non-epidural” category actually received epidurals, the rate of malpositioned babies associated with epidural is even higher (11% vs. 2%).⁴ Furthermore, malpositioned babies are also significantly more likely to require an operative delivery. Critics of this theory will argue that rather than epidurals causing malpositioned babies, mothers with malpositioned babies often experience longer, more painful labors and are simply more likely to request an epidural. The evidence to date is insufficient to unravel that chicken versus egg debate, but other factors associated with epidurals that also are thought to increase the second stage of labor and make operative delivery more common are simply the numbness and general muscle weakness generated by the epidural. Given the higher rates of perineal lacerations and neonatal complications observed in operative deliveries, it is understandable that women want to avoid procedures that increase their risk of requiring instrumentation in their delivery.

Increased Rates of Pitocin Administration

Not surprisingly given the longer labors observed in women with epidurals, epidurals are also associated with an increased chance of receiving pitocin.³ Pitocin may also be more freely given to women with epidurals because, once the epidural is in place, most women will not experience a difference in their labor discomfort as a result of the pitocin and providers may simply want to shorten the labor whether or not the labor is prolonged. Many women have a strong desire to avoid pitocin, for the numerous reasons discussed previously, and this desire alone may be enough for them to want to avoid an epidural.

Hypotension

Hypotension is defined as a 20% drop in systolic blood pressure and is one of the more common side effects of epidural administration, occurring in approximately 10% of women who receive epidurals. Women are given fluid boluses prior to an epidural to decrease the likelihood of this effect and, when they occur, these episodes are typically treated with maternal position changes which displace the uterus off the large vessels of the pelvis and improve blood flow back to the heart, additional fluid boluses, and occasionally vasopressors, medications that increase maternal heart rate and blood pressure. Possible consequences of epidural-related hypotension are maternal nausea and vomiting and feelings of dizziness, as well as fetal heart rate changes and distress as a consequence of poor uterine perfusion. Occasionally, the episodes can be significant enough and the fetal response poor enough to warrant an emergency cesarean.

Pruritus or Itching

Itchiness is the most common side effect experienced with epidurals, occurring in 30% of women, and spinal anesthesia, occurring in 58% of women. It is often mistakenly believed to be due to a histamine release, but antihistamines are ineffective in treating it and can cause decreased milk supply after birth. Opioid antagonists have been shown to help, but are usually not given because they counteract the pain relief benefits.

Maternal Fever

Maternal fever during labor is another common side effect associated with epidural use. The exact rate is not clear, as it is often challenging to isolate the number of women with a fever from another cause from women experiencing fever due to epidural alone. However, one study of over 2500 women receiving epidurals demonstrated that temperatures exceeding 99.5°F occurred in 44.8% of patients, as opposed to 14.6% in the non-epidural group.⁵ The association between epidural and maternal fever has also been demonstrated in several randomized controlled trials, though there has been much debate about whether these studies were skewed by compounding variables, such as longer labors, more vaginal examinations, or increased use of additional medications, such as pitocin. It is also unclear whether the etiology of fevers associated with epidurals is inflammatory or a disruption in thermoregulatory processes.

The consequences of maternal fever during labor are numerous. Elevated temperatures are associated with an increase in maternal heart rate, cardiac output, and oxygen consumption, which are rarely harmful to healthy laboring women, but can be dangerous in women with cardiac or pulmonary diseases or complications of pregnancy. There is also often an associated change in labor management in response to maternal fever. Women with fevers are twice as likely to undergo either an operative vaginal delivery or a cesarean section than those without fever. It is uncertain whether this is due to an effect of the fever on the labor process or if care providers are more likely to intervene in the setting of a maternal fever for fear of worse complications if delivery is delayed. Maternal fever also typically prompts a sepsis, or infection, evaluation in the newborn, which can mean something as minor as simple blood tests and observation or as significant as automatic admission to the Neonatal Intensive Care Unit and prophylactic antibiotic administration, depending on the hospital protocol. There are conflicting studies addressing whether fever itself is dangerous for babies, with most studies indicating permanent neurological harm only in the setting of infectious, inflammatory fevers, however all babies born in the setting of a maternal fever were at higher risk for seizures, low APGAR scores, and the need for cardiopulmonary resuscitation at birth.⁶

Accidental Dural Puncture and Postdural Puncture Headache or “Spinal Headache”

When the epidural needle is inserted too far and accidentally punctures the dural sac surrounding the spinal cord, small amounts of cerebrospinal fluid can leak out and a postural “spinal headache” results. This is a severe headache that tends to worsen with sitting or standing and improves with lying down, significantly limiting a new mother’s ability to care for their baby. While it will ultimately go away on its own, more than 80% of women who experience this end up being treated due to the severity of the symptoms. “Spinal headaches” are treated with what is known as a “blood patch,” where some of the patient’s own blood is inserted into the epidural space, helping to seal the puncture site. The risk of an accidental puncture is approximately 1.5%, with 52% of those punctures developing into spinal headaches.⁷

Serious Complications: Nerve Injury, Infection, and Epidural Hematomas

One of the most common fears women express about epidurals is that it will “paralyze them” or otherwise damage their spine. Fortunately, the risk of serious neurological complications of epidurals is quite low. In a review of over 300,000 women who received epidurals, the rate of permanent nerve injury was shown to be as low as 0.6 in 100,000.⁸ The risk of an epidural abscess or meningitis following an epidural is also extremely low, with each complication complicating only 0.2 to 3.7 per 100,000 obstetrical epidurals.⁹ The incidence of an epidural hematoma, a blood clot forming in the epidural space causing compression and injury to the spinal cord, is even more uncommon, affecting only one patient in a review of six surveys involving more than 1 million obstetric epidural procedures.¹⁰

Lower Breastfeeding Rates

Another commonly expressed fear among laboring women regarding epidural administration is that the medication will reach the baby and result in some harm or “drugging” of the baby and negatively impact breastfeeding. This concern is often listed in natural childbirth texts as one of the reasons women should avoid an epidural. However, the medical evidence demonstrating this is lacking. An observational study of nearly 200 women in 1999 failed to show any effect of epidural analgesia on breastfeeding success.¹¹ A larger Italian observational study in the same year also failed to show any impact of epidurals on breastfeeding rates, which are universally high in Italian women, though it did show lower rates in women who had received general anesthesia during cesarean sections.¹² A later randomized controlled study did demonstrate that larger doses of fentanyl in epidurals were associated with negative impacts on breastfeeding, with mothers receiving the highest doses reporting more problems with breastfeeding in the first 24 hours and lower rates of breastfeeding at 6 weeks.¹³ However, another larger randomized control trial by Wilson et al.¹⁴ failed to show this association, with women showing similar rates of breastfeeding irrespective of epidural use, dosing, or type of administration. While there is certainly room for more study, it does not appear that epidurals significantly impact breastfeeding success and all current research supports that epidurals have less impact on breastfeeding than IV narcotic pain medications in labor.¹⁵

Chronic Back Pain

Back pain in pregnancy and after delivery is common. At least 40% of women report some degree of gestational back pain and some studies show a rate up to 90%. There are several reasons for this. During pregnancy, a hormone relaxin is secreted that results in increased mobility of the joints, which makes women more prone to strain injuries of the spine. Another causal factor is the biomechanical realities of pregnancy, where the enlarging uterus shifts the center of gravity forward, requiring pregnant women to lean backwards to maintain their balance. This puts additional strain on the muscles of the lower back, in particular, and increases the risk of injury. Postpartum backaches occur in up to two-thirds of women after delivery, though they resolve in the majority of women. Nonetheless, up to 7% of women still report significant back pain over 1 year from delivery.¹⁶

Chronic back pain was first linked to epidural use in 1990, when a large study was done in the United Kingdom, examining the effect of epidural on the development of back pain. Over 30,000 women were sent questionnaires inquiring about back pain and epidural use. Less than half of those sent the questionnaires responded, but the results were concerning, with women who received an epidural reporting significantly higher rates of back pain. The examiners conducted a very thorough statistical analysis, showing even that women who had planned cesareans had no difference in back pain rates whether or not they received epidural analgesia, whereas women who had epidurals and emergency cesareans during labor did demonstrate an increased rate of back pain, supporting the theory that prolonged immobility with epidural analgesia and the resultant damage was the culprit behind this association. They estimated that epidurals were associated with an 8 in 100 chance of developing chronic back pain after delivery.¹⁷

There was one major problem with this study, however. Given that less than half of those surveyed responded, the study likely overrepresented women with back pain, because those with pain were much more likely to return the survey than those who felt fine. Later, better designed studies have failed to show a link between epidurals and back pain and the 2011 Cochrane Review of the data examining this concern also determined that epidurals do not increase the risk of chronic back pain.³

The million dollar question for most women considering an epidural is whether it will increase their chance of ending up in a cesarean section and fear of a cesarean is one of the main reasons women cite for choosing to forgo the pain relief epidurals offer. Unfortunately, for women trying to make an informed decision regarding epidurals, the evidence is extremely confusing and the interpretations of it vary widely. In the media, for every strongly supported article stating that epidurals increase the likelihood of cesarean and advocating for nonmedical management of labor pain, there is another article explicitly refuting this claim and encouraging women to utilize epidurals without concern. So, who is right?

That question is incredibly difficult to answer because labor is a complex and poorly understood process, influenced by a great number of factors, and the women going through that process are equally complicated and diverse. The initial concern about a possible link between epidurals and cesarean was raised by Thorp et al. (1989),¹⁸ who observed a significantly higher rate of cesarean in patients who had received epidurals when compared to women who either received narcotics or had not received any pharmacological pain relief in labor. In the nearly 20 years that followed, study after study was performed trying to tease out the truth regarding the association. However, studying the subject has, in itself, been a considerable challenge and, consequently, the results and conclusions from these studies must be taken with a grain of salt. First and foremost, it is difficult to design a randomized controlled trial, the gold standard of medical evidence, because providers are unable to be blinded to the therapy they are studying and professional biases could potentially alter their management. It is also difficult to convince women to sign up for a study that may preclude them obtaining an epidural, which is the safest, most effective form of pharmacologic pain relief currently available. Furthermore, many providers feel it is unethical to even conduct a study that does not offer some form of pharmacologic pain relief and therefore all but 5 of the 38 randomized trials to date have compared epidurals to narcotics, not epidurals to nonpharmacologic pain relief methods.

To complicate things further, all of the studies have been conducted within the framework of the medically managed labor model, so it is uncertain whether women who were in the “non-epidural” groups were offered appropriate nonpharmacological pain management options, such as ambulation, hydrotherapy, or comfort positioning, what preparation, if any, they had for an unmedicated delivery, and to what degree either group were medically augmented in their labor with pitocin and artificial rupture of membranes. Hence, critics argue these studies are not adequately comparing intervention to no intervention, they are only comparing degrees of intervention and no study to date has adequately compared the low intervention, natural approach to the medically managed approach. Finally, some studies did not have comparable numbers of multiparous patients in each group, who are very likely to have a vaginal delivery regardless of labor interventions, and each of the studies had patients in the “epidural group” who progressed too rapidly to receive an epidural, as well as patients in the “no epidural group” who ultimately received an epidural, which makes interpretations of the results confusing.

So, keeping all these limitations in mind, what does the data show? In summary, the data shows an increased risk of many factors associated with cesarean, but not necessarily an increased risk of cesarean itself. Patients with epidurals are more likely to experience maternal fever, pitocin augmentation, continuous fetal monitoring, prolonged labor, malpositioned babies, and even cesarean specifically for fetal distress but overall rates of cesarean are not statistically comparable whether a woman has an epidural or not.³ This is confusing. How does an increase in things that can lead to a cesarean not translate to an increased rate of cesareans themselves?

Certainly, many observational studies have shown the opposite. For example, in one study by Klein et al.,¹⁹ which grouped patients according to their providers overall rate of epidural use, first-time mothers cared for by providers who utilized epidurals less than 40% of the time were observed to have a cesarean rate of 14.8%, while those who had a provider who utilized epidurals with over 70% of their patients had a cesarean rate of 23.4%. Providers who utilized epidurals at a higher rate were also shown to admit patients earlier in the labor process, utilize continuous fetal monitoring and pitocin augmentation at higher rates, and delivered more babies who were malpositioned and/or required NICU care. This suggests that epidural is a marker of labor management style that leads to more cesareans. Indeed, in the personal narratives of many new mothers and in the judgment of many in the natural birth community, an epidural, similar to an induction, is often the first step in a cascade of medical interventions that ultimately end in an operating room.

Another thorough observational study that attempted to minimize the effects of several confounding variables, such as noncompliance within the study groups and employment of different medical interventions like continuous monitoring, found a similar association of epidural with cesarean. Over 50,000 well-matched women were compared and even when groups were analyzed after excluding for confounding factors such as the setting where they delivered, their provider type, and the use of other medical interventions, cesarean was still two times more likely when epidurals were utilized. Investigators even performed a calculation in which they eliminated patients with occiuput posterior, or sunny-side up, babies from the analysis. This was done in order to solve the “chicken versus egg” debate concerning whether epidurals cause malpositioned babies or are simply utilized more frequently in the setting of fetal malposition. Even after patients with malpositioned babies were excluded, patients with an epidural were still shown to undergo cesarean at a higher rate.¹⁹

Other observational studies that have shown an increased incidence include a Danish cohort of over 2000 low-risk nulliparous women who were shown to have a higher risk of emergency cesarean with epidural use, a retrospective review of 1733 low-risk first-time mothers that demonstrated a 3.7-fold increased risk of cesarean with epidural, with higher rates observed the earlier the epidural was administered, and a multicenter study including over 2000 women which examined several risk factors for labor dystocia and found epidurals to have the highest association with protracted labor.^21–23 Several individuals have reexamined the data used in the Cochrane Review to try and understand the apparent disconnect between these observational studies, as well as their own clinical experience, and the randomized trials. One critic pointed out that the largest trial contributing to the results of the review was performed in an institution that already had a very low rate of cesarean, 12%, which is not indicative of national averages and suggests that factors which usually compound the effect of an epidural on the labor process may not be an issue at this particular institution. Furthermore, in most of the studies in the review, only patients in spontaneous labor, after 4 cm dilation, were randomized, perhaps merely demonstrating that epidurals in active labor do not alter the incidence of cesarean.²⁴

Additional studies and a later review attempted to address this later critique, examining the timing of epidural as it related to cesarean rates. Nine studies were included in the Cochrane Review that attempted to determine if early epidurals were associated with more cesareans than later epidurals. Their conclusion was that timing of epidural had no impact on cesarean rate.²⁵ The overall quality of the review was good, however, critics have pointed out there were some limitations that should be considered. Six of the trials included in the review had significant overlap between their “early” and “late” epidurals and none of the trials used the current standard for true active labor of 6 cm, as defined by ACOG, meaning a significant portion of the “late” epidurals could actually have been administered in the latent stage of labor as we now understand it. Finally, there was also considerable variation in the overall rates of cesarean observed between what would otherwise be considered comparable groups of patients with similar risks of cesarean, which points to practice variations between the institutions that conducted the studies which could be masking the effect of epidural timing on the rate of cesarean.²⁶

Ultimately, however, the question of whether a late epidural is better than an early epidural is significantly less important than whether epidurals, in general, contribute to the rising cesarean rate. Overall, the evidence suggests that epidural itself may be less important than the care philosophy in which it is provided. A recent study found that labor and delivery units with the most proactive or interventional management style and philosophy are associated with the highest rates of cesarean section, as well as postpartum hemorrhage, blood transfusions, and prolonged hospital stays.²⁷ Furthermore, none of the studies to date have explored what contribution, if any, the patient may have on the process. A patient planning a natural birth who prepares for a natural birth and has a plan in place to manage their discomfort nonpharmacologically is very different from a patient randomized to not receive an epidural who relies on narcotics or simply white-knuckles it through their labor. What is needed are studies comparing spontaneously laboring patients, both with and without intention for an epidural, in a low-intervention model with spontaneously laboring patients, with and without intention for an epidural, in a traditional high-intervention medical model. This could start to unravel how much effect the provider, the patient herself, and the epidural is having on cesarean rates. But in the absence of that information, the honest answer to the million dollar question is simply we do not really know. Epidural is associated with several things that have been shown to contribute to cesareans, but the degree to which those things will impact any individual woman is unable to be determined. In conclusion, women who want epidurals should be able to obtain them when they wish and both pharmacologic and nonpharmacologic alternatives to epidurals should be readily available to any woman who wishes to make an epidural her plan B.

I would like to utilize Hydrotherapy for Pain Relief