Epidurals: Food for Thought

In a series of posts on our sister blog Science & Sensibility, Dr. Michael Klein, family practice physician, pediatrician, neonatologist and Senior Scientist for the Centre for Developmental Neuroscience and Child Health and the Family Research Institute, shares the research, history and implications -- positive and negative -- for epidural use. Over the next few weeks at Giving Birth with Confidence, we'll be sharing snippets of Dr. Klein's posts on epidurals for your review.

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 supportfrom 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 are employed by the hospital, their primary allegiance is to the institution, and they are professionally 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 analgesia is 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 undesireable 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 (3^rd and 4^th 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.

Photo from Wikimedia.