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

Published: February 20, 2011

Tags