Should I use an epidural during childbirth?
Alright, hang on tight folks. We’re going to get into it all! The good, the bad and the ugly around epidural use during labour.
By far the most common misconception I hear about doulas, is that we ALL want our clients to have unmedicated births. As if the ultimate success in childbirth is doing it unmedicated And while perhaps this is true for some doulas this couldn’t be further from the truth in my practice (and any doula that believes there is only one way to birth, I’d run as far away from as possible).
This becomes SO apparent when we talk about epidurals.
Epidurals are a tool that can be used for a specific purpose during labour, and when they are used well, they can be INCREDIBLE.
AND, they also carry with them risks.
I was reminded of this, at my most recent birth.
STORY TIME…
Client B was 5 cm’s dilated, and her labour had stalled. She had been labouring for about 16 hours through the night and was EXHAUSTED. While her contractions were by no means light, they weren’t progressing in force, duration or frequency. She was in a limbo state of continuing the exhausting work of labour, without any significant progress.
After a cervical check, we deduced baby’s position was likely the issue so we went to work trying ALL the things to change baby’s position. We got her in specific labour positions that would encourage baby to rotate, we helped her with pelvic movement, lunges, got her in a water bath to try to help her relax … and through it all, baby did not want to turn.
Fortunately, baby was tolerating contractions perfectly and so we had no immediate medical concerns.
But B was exhausted.
B had a few options. She could continue to labour as she was, hoping that what we were doing would eventually turn baby (or they would turn on their own). She could also get an epidural and rest. By this point she had been awake for almost 30 hours and was exhausted. After explaining all the benefits, risks and alternatives to her (which we had also done in her prenatal appointments), she chose to rest.
She was given an epidural along with a small dose of Pitocin (a synthetic form of oxytocin) to help with her contractions and she closed her eyes and went to sleep. (The use of Pitocin is another topic I will talk about in another blog post!). Three hours later she woke up, a new person. She was rested, rejuvenated and ready to go. Her midwife did a cervical check and not only was she fully dilated, but baby had dropped down so low we could see their head!! Less than 30 minutes later she breathed that baby out with absolutely no tearing.
Was an epidural medically necessary at that point? No.
Were there risks? Absolutely (and I’ll go over these in this post)
B was explained all the risks and benefits of both options and was given the autonomy to choose which option was right for her in that moment. And she knew what she needed in that moment.
I don’t share this story because I believe everyone should get an epidural. Far from. I share it because despite knowing all the research and having all the facts, in the end, it is about TRUSTING that the birthing person knows what is best for them.
I don’t care if you choose to have an epidural or not at your birth. What I care about is that you have all the information to make an informed decision based on your specific situation and your intuitive knowledge about yourself. So that’s what I’m going to share here…
In this blog post I will discuss:
What an epidural is and how it is administered.
The benefits to receiving an epidural
The risks associated with epidural use
Some alternatives to epidural use.
Much of the research in this blog post comes from the 2018 Cochrane review on epidural use, and if you want to dive into the research yourself you can find that here.
What is an epidural?
An epidural is a form of medical pain management that is used commonly during labour. To administer an epidural, a needle is inserted into the back and then a small catheter is fed through into the epidural space of the spine where the pain medication is administered. The actual drug cocktail along with the dose will differ from country to country and even hospital to hospital.
Some hospitals will offer what is referred to as a ‘walking epidural’ which is a bit of a misnomer because you will likely not actually be allowed to ‘walk around’. It is essentially a lower dose of medication blocking the painful stimuli while preserving motor function. While epidurals block pain signals they do not effect touch or pressure.
Epidurals usually take about 10-20 minutes to start working, and dose will sometimes have to be adjusted. They can only be administered by an anaesthesiologist in a hospital, which means they are not available for home births or birth center births. As well, the anesthesiologist needs to be available at the time, which means they can sometimes take some time to organize.
In Canada, approximately 60% of birthers use an epidural during their labour.
Benefits of an epidural
The primary benefit of epidurals is PAIN RELIEF. Epidurals are considered the gold standard for pain management during labour. A Cochrane review in 2018 found that they typically reduce pain by 3.5 points (on a 1-10 pain scale). Anecdotally, many folks experience complete pain relief from an epidural. That being said, about 1 in 8 folks do not experience adequate pain relief from an epidural. When compared with other forms of medical pain relief, epidurals are considered safer for baby than opioid medications given through IV. Overall, the majority of people who receive an epidural during labour are extremely satisfied with the amount of pain relief they experience.
Epidurals can help a birthing person relax and get sleep if needed during a long and exhausting labour.
In the case that an emergency cesarean is necessary, if an epidural is in place, it can be used for the surgery. If no epidural is in place, you may need a spinal (which provides immediate pain relief) or if time is really essential then general anesthesia will be required which carries with it much more risk.
There is also some evidence to suggest that if a birthing person isn’t coping well with labour and is experiencing high levels of stress, this could lead to decreased blood flow to the baby. An epidural could decrease that level of stress and thus positively affect the baby.
Risks to an epidural
Epidurals can result in various side effects for the birthing person, some more common than others.
You are much more likely to experience low blood pressure from an epidural. To account for this risk you will typically be hooked up to IV fluids.
You are more likely to experience a fever and given antibiotics due to the possible risk of infection.
Epidurals slow down both the first and second stages of labour (the first stage being the dilation phase and the second stage being the pushing phase). As a result, you are more likely to need Pitocin augmentation (a synthetic form of Oxytocin) which carries with it its own risks.
You are more likely to require an assisted vaginal delivery (the use of forceps or vacuum during the pushing phase) which is more likely to lead to tearing of the perineum. Interestingly, in the research when only studies after 2005 were included this risk no longer existed, so it could be that more modern epidurals (with lower doses) have accounted for this risk.
Your ability to move after an epidural will likely be impacted. As I mentioned above, some hospitals will offer ‘lower dose epidurals’ but even with these, many folks report less ability to move than they would like. This is likely associated with the longer labour times.
Some other risks associated with epidurals are nausea (although labour itself can often result in nausea), itchiness, infection at the sight of the needle (rare), and a temporary sore back.
Death or serious complications like seizures, severe breathing difficulty and nerve damage are extremely rare, so much so that a study looking at this spanning 10 years found 0 deaths from epidural.
While there is no difference in overall rate of cesareans, the research on this had very low cesarean rates (11-12%) which does not mirror real life cesarean rates in Canada or America so it’s hard to know if these clinical trials would transfer well to real life situations.
Lastly, It’s also important to understand that the process of having an epidural can instantly ‘medicalize’ your birth. While it may seem like you are just getting the epidural, in reality it results in a ripple effect of interventions. Once an epidural is administered, you will need to be hooked up to an IV. You’ll likely need continuous blood pressure monitoring, and you will more likely need Pitocin to help augment labour. You will have a catheter inserted into the bladder due to loss of bladder control and the hospital may require you to have continuous fetal monitoring. All of this can really change the feel of your birth.
Alternatives to epidural use
There are many alternatives to epidural use which I will list, but not go into detail on in this post. While many of the non-medicalized techniques carry with them fewer risks, they typically require more support and some form of prenatal education or preparation. Some of these include:
Injectable Opioids
Nitrous Oxide
Acupressure
Breathing techniques
Touch/Massage
Relaxation
Hydrotherapy
TENS machine
So here’s the bottom line…
Epidurals are typically a really effective pain management tool, however they carry with them significant risks. In certain situations, an epidural may be the best option for you, regardless of these risks. Where I believe issues arise, is when folks aren’t explained the risks, and don’t understand that there are other options available to them. When labour begins and you are suddenly overcome by the intensity of the sensations you are experiencing, an epidural may seem like your only option.
Preparing for birth through childbirth education classes or doula support will help you understand all the options available to you BEFORE you go into labour and help you make an informed decision in the moment.
