Epidural pain relief is an increasingly popular choice for Australian
women in the labour ward. Up to one-third of all birthing women have an
epidural,(1) and it is especially common amongst women having their first
babies.(2) For women giving birth by caesarean section, epidurals are
certainly a great alternative to general anaesthetic, allowing women to
see their baby being born, and to hold and breastfeed at an early stage:
however their use as a part of a normal vaginal birth is more
questionable(3)
There are several types of epidural used in Australian hospitals. In a
conventional epidural, a dose of local anaesthetic is injected through the
lower back into the epidural space, around the spinal cord. This numbs the
nerves which bring sensation from the uterus and birth canal.
Unfortunately, the local anaesthetic also numbs the nerves which control
the pelvic muscles and legs, so with this type of epidural, a woman
usually cannot move her legs and, unless the epidural has worn off, cannot
push her baby out, in the second stage of labour.
More recent forms of epidurals use a lower dose of local anaesthetic,
usually combined with an opiate, such as pethidine, morphine or fentanyl
(sublimaze). With this low-dose or combination epidural, most women can
move around with support; however the chance of a woman being able to give
birth without forceps is still low(4). Another form of epidural, popular
in the US, is the CSE, or combined spinal-epiudural, where a one-off dose
of opiate, with or without local anaesthetic, is injected into the spinal
space, very close to the end of the spinal cord. This gives pain relief
for around 2 hours, and if further pain relief is needed, it is given as
an epidural. These forms of "walking epidural" may seem advantageous, but
being attached to a CTG machine to monitor the baby, and hooked up to a
drip which is also a requirement when an epidural is in place, can make
walking impossible.
Many women have a good experience with epidurals. Sometimes the relief
from pain can allow a woman to rest and relax sufficiently to go on and
have a good birth experience. However deciding to use an epidural for pain
relief can also lead to a "cascade of intervention", where an otherwise
normal birth becomes highly medicalised, and a woman feels that she loses
her control and autonomy. Often the decision to accept an epidural is made
without an awareness of these, and other, significant risks to both mother
and baby.
Although the drugs used in epidurals are injected around the spinal
cord, substantial amounts enter the mothers blood stream, and pass through
the placenta into the baby's circulation. Most of the side effects of
epidurals are due to these "systemic", or whole-body effects.
One of the most commonly recognised side effects is a drop in blood
pressure. Up to one woman in eight will have this side effect to some
degree(5), and for this reason, extra fluids are usually given through a
drip to prevent problems. A drop in the mother's blood pressure will
affect how much of her blood is pumped to the placenta, and can lead to
less oxygen being available to the baby.
An epidural will often slow a woman's labour, and she is three times
more likely to be given an oxytocin drip to speed things up(6, 7). The
second stage of labour is particularly slowed, leading to a three times
increased chance of forceps(8). Women having their first baby are
particularly affected; choosing an epidural can reduce their chance of a
normal delivery to less than 50%(9).
This slowing of labour is at least partly related to the effect of the
epidural on a woman's pelvic floor muscles. These muscles guide the baby's
head so that it enters the birth canal in the best position. When these
muscles are not working, dystocia, or poor progress, may result, leading
to the need for high forceps to turn the baby, or a caesarean section.
Having an epidural doubles a woman's chance of having a caesarean section
for dystocia(10).
When forceps are used, or if there is a concern that the second stage
is too long, a woman may be given an episiotomy, where the perineum, or
tissues between the vaginal entrance and anus, are cut to enlarge the
outlet and hurry the birth. Stitches are needed and it may be painful to
sit until the episiotomy has healed, in 2 to 4 weeks.
As well as numbing the uterus, an epidural will numb the bladder, and a
woman may not be able to pass urine, in which case she will be
catheterised. This involves a tube being passed up from the urethrer to
drain the bladder, which can feel uncomfortable or embarrassing.
Other side effects of epidurals vary a little depending on the
particular drugs used. Pruritis, or generalized itching of the skin, is
common when opiate drugs are given. It may be more or less intense and
affects at least 1/4 of women(11 12): morphine or diamorphine are most
likely to cause this. Morphine also causes oral herpes in 15% of
women(13).
All opiate drugs can cause nausea and vomiting, although this is less
likely with an epidural around 30%(14) than when these drugs are given
into the muscle or bloodstream, where larger doses are needed. Up to 1/3
of women with an epidural will experience shivering(15), which is related
to effects on the bodies heat-regulating system.
When an epidural has been in place for more than 5 hours, a woman's
body temperature may begin to rise(16). This will lead to an increase in
both her own and her baby's heart rate, which is detectable on the CTG
monitor. Fetal tachycardia, or fast heart rate can be a sign of distress,
and the elevated temperature can also be a sign of infection such as
chorioamnionitis, which affects the uterus and baby. This can lead to such
interventions as caesarean section for possible distress or infection, or,
at the least, investigations of the baby after birth such as blood and
spinal fluid samples, and several days of separation, observation, and
possibly antibiotics, until the results are available(17).
Less common side effects for a woman having an epidural are; accidental
puncture of the dura, or spinal cord coverings, which can cause a
prolonged and sometimes severe headache (1 in 100)(18) ongoing numb
patches, which usually clear after 3 months(1 in 550)(19); and weakness
and loss of sensation in the areas affected by the epidural, (4-18 in
10,000) also usually resolving by 3 months(20).
More serious but rare side effects include permanent nerve damage;
convulsions and heart and breathing difficulties (1 in 20,000)(21) and
death attributable to epidural. (1 in 200,000)(22) When opiates are used,
a woman may experience difficulty in breathing which comes on 6 to 12
hours later.(23)
There is a noticeable lack of research and information about the
effects of epidurals on babies.(24) Drugs used in epidurals can reach
levels at least as high as those in the mother(25), and because of the
baby's immature liver, these drugs take a long time- sometimes days- to be
cleared from the baby's body.(26) Although findings are not consistent,
possible problems, such as rapid breathing in the first few hours(27) and
vulnerability to low blood sugar(28) suggest that these drugs have
measurable effects on the newborn baby.
As well as these effects, babies can suffer from the interventions
associated with epidural use; for example babies born by caesarean section
have a higher risk of breathing difficulties.(29) When monitoring of the
heart rate by CTG is difficult, babies may have a small electrode screwed
into their scalp, which may not only be unpleasant, but occasionally can
lead to infection.
There are also suggestions that babies born after epidurals may have
difficulties with breastfeeding(30,31) which may be a drug effect, or may
relate to more subtle changes. Studies suggest that epidurals interfere
with the release of oxytocin(32) which, as well as causing the let-down
effect in breastfeeding, encourages bonding between a mother and her
young(33).
Epidural research, much of it conducted by the anaesthetists who
administer epidurals, has unfortunately focussed more on the pro's and
con's of different drug combinations than on possible serious
side-effects(34). There have been, for example, no rigorous studies
showing whether epidurals affect the successful establishment of
breastfeeding(35).
Several studies have found subtle but definite changes in the behaviour
of newborn babies after epidural(36,37,38) with one study showing that
behavioural abnormalities persisted for at least six weeks(39). Other
studies have shown that, after an epidural, mothers spent less time with
their newborn babies(40), and described their babies at one month as more
difficult to care for.(41)
While an epidural is certainly the most effective form of pain relief
available, it is worth considering that ultimate satisfaction with the
experience of giving birth may not be related to lack of pain. In fact, a
UK survey which asked about satisfaction a year after the birth found that
despite having the lowest self-rating for pain in labour (29 points out of
100), women who had given birth with an epidural were the most likely to
be dissatisfied with their experience a year later.(42)
Some of this dissatisfaction was linked to long labours and forceps
births, both of which may be a consequence of having an epidural. Women
who had no pain relief reported the most pain (70 points out of 100) but
had high rates of satisfaction.
Pain in childbirth is real, but epidural pain relief may not be the
best solution. Talk about other options with your care-givers and friends.
With good support, and the use of movement, breathing and sound, most
women can give themselves, and their babies, the gift of a birth without
drugs.
References:
1 Perinatal Statistics, Queensland 1996. Queensland
Health 1998. At thepresent time, national figures for epidural use are not
collected. 2 Dr Steve Chester, Head of Anaesthetics Dept, Royal Women's
Hospital, Melbourne. Around 45% of primiparous women at RWH have an
epidural. Personal Communication 3 World Health Organisation. Care in
Normal birth: A Practical Guide..P 16. WHO 1996 4 Russell R, Reynolds
F. Epidural infusion of low-dose bupivicaine and opioid in labour. Does
reducing the motor block increase the spontaneous delivery rate?
Anaesthesia 1996; 51(5): 266-273 5 Webb RJ, Kantor GS. Obstetrical
epidural anaesthesia in a rural Canadian hospital. Can J Anaesth 1991;
39:390-393 6 Ramin SM, Gambling DR, Lucas MJ et al. Randomized trial of
epidural versus intravenous analgesia during labor. Obstet Gynecol 1995;
86(5): 783-789 7 Howell CJ. Epidural vs non-epidural analgesia in
labour. [Revised 6 May 1994] In: Keirse MJNG, Renfrew MJ, Neilson JP,
Crowther C. (eds) Pregnancy and Childbirth Module. In: The Cochrane
Pregnancy and Childbirth Database. (database on disc and CD-ROM ) The
Cochrane Collaboration; Issue 2, Oxford: Update Software 1995 (Available
from BMJ publishing group, London) 8 Thorp JA, Hu DH, Albin RM, et al.
The effect of intrapartum epidural analgesia on nulliparous labor; a
randomized, controlled, prospective trial. Am J Obstet Gynecol 1993;
169(4): 851-858 9 Paterson CM, Saunders NSG, Wadsworth J. The
characteristics of the second stage of labour in 25069 singleton
deliveries in the North West Thames Health Region. 1988. Br J Obstet
Gynaecol 1992;99:377-380 10 Thorp JA, Meyer BA, Cohen GR et al.
Epidural analgesia in labor and cesarean section for dystocia. Obstet
Gynecol Surv 1994; 49(5): 362-369 11Lirzin JD, Jacquintot P, Dailland
P, et al. Controlled trial of extradural bupivicaine with fentanyl,
morphine or placebo for pain relief in labour. Br J Anaesth 1989; 62:
641-644 12Caldwell LE, Rosen MA, Shnider SM. Subarachnoid morphine and
fentanyl for labor analgesia. Efficacy and adverse effects. Reg Anesth
1994;19:2-8 13 John Paull, Faculty of Anaesthetists, Melbourne. Quoted in:
"The perfect epidural for labour is proving elusive" New Zealand Doctor.
21 Oct 1991 14 as above 15 Buggy D, Gardiner J. The space blanket
and shivering during extradural analgesia in labour.
Acta-Anaesthesiol-Scand 1995; 39(4): 551-553 16 Camman WR, Hortvet LA,
Hughes N, et al. Maternal temperature regulation during extradural
analgesia for labour. Br J Anaesth 1991;67:565-568. 17 Kennell J, Klaus
M, McGrath S, et al. Continuous emotional support during labor in a US
hospital. JAMA 1991;265:2197-220 18 Stride PC, Cooper GM. Dural taps
revisited: a 20 year survey from Birmingham Maternity Hospital.
Anaesthesia 1993; 48(3):247-255 19Epidurals for pain relief in labour:
Informed choice leaflet for women. MIDIRS and the NHS centre for Reviews
and dissemination 1997. 20 Epidural pain relief during labour; Informed
choice for professionals. MIDIRS and the NHS centre for Reviews and
dissemination 1997. 21 see 13 22see 13 23 Rawal N, Arner S et al
Ventilatory effects of extradural diamorphine.Br J Anaesthesia
1982;54:239 24 Howell CJ, Chalmers I. A review of prospectively
controlled comparisons of epidural with non-epidural forms of pain relief
during labour. Int J Obstet Anaesth 1992;1:93-110 25Fernando R, Bonello
E et al. Placental and maternal plasma concentrations of fentanyl and
bupivicaine after ambulatory combined spinal epidural (CSE) analgesia
during labour. Int J Obstet Anaesth 1995;4:178-179 26 Caldwell J,
Wakile LA, Notarianni LJ et al. Maternal and neonatal disposition of
pethidine in child birth- a study using quantitative gas
chromatography-mass spectrometry. Lif Sci 1978;22:589-96 27 Bratteby
LE, Andersson L, Swanstrom S. Effect of obstetrical regional analgesia on
the change in respiratory frequency in the newborn. Br J Anaesth 1979;
51:41S-45S 28Swanstrom S, Bratteby LE. Metabolic effects of obstetric
regional analgesia and of asphyxia in the newborn infant during the first
two hours after birth I. Arterial blood glucose concentrations. Acta
Paediatr Scand 1981; 70:791-800 29Enkin M, Keirse M, Renfrew M, Neilson
J. A Guide to Effective Care in Pregnancy and Childbirth. P 287 Oxford
University Press 1995 30 Smith A. Pilot study investigating the effect
of pethidine epidurals on breastfeeding. Breastfeeding Review, Nursing
Mothers Association of Australia. V5 no1 May 1997. 31 Walker M. Do
labor medications affect breastfeeding? J Human Lactation 1997;13(2)
131-137 32Goodfellow CF, Hull MGR, Swaab DF et al. Oxytocin deficiency
at delivery with epidural analgesia. Br J Obstet Gynaecol 1983;
90:214-219 33 Insel TR, Shapiro LE. Oxytocin receptors and maternal
behavior. In Oxytocin in Maternal Sexual and Social Behaviors. Annals of
the New York Academy of Sciences, 1992 Vol 652. Ed CA Pedersen, JD
Caldwell, GF Jirikowski and TR Insel pp 122-141 New York, New York Academy
of Science 34 Howell CJ, Chalmers I A review of prospectively
controlled comparisons of epidural with non-epidural forms of pain relief
during labour. Int J Obstet Anaesth 1992 1: 93-110 35 See 31 36
Scanlon JW, Brown WU, Weiss JB Alper MD. Neurobehavioral responses of
newborn infants after maternal epidural anesthesia. Anesthesiology, 1974;
40: 121-128 37 Morikawa S, Ishikawa I, Kamatsuki H, et al.
Neurobehavior and mental development of newborn infants delivered under
epidural analgesia with bupivicaine. Nippon Sanka 1990; 42:
1495-1502 38 Lester BM, Heidelise A, Brazelton TB. Regional obstetric
anesthesia and newborn behavior: a synthesis toward synergistic
effects.Child Dev 1982; 53;687-692 39 Rosenblatt DB, Belsey EM,
Lieberman BA et al. The influence of maternal analgesia on neonatal
behaviour II epidural bupivicaine. Br J Obstet Gynecol 1981
24;649-670 40 Seposki C, Lester B, Ostenheimer GW, Brazelton, TB. The
effects of maternal epidural anesthesia on neonatal behavior during the
first month. Dev Med Child Neurol 1992:34;1072-1080 41 Murray AD, Dolby
RM, Nation RL, Thomas DB.Effects of epidural anesthesia on newborns and
their mothers. Child Dev 1981; 82:71-82 42 Morgan BM, Bulpitt CJ,
Clifton P, Lewis PJ. Analgesia and satisfaction in childbirth (the Queen
Charlotte's 1000 mother survey) Lancet 1992; 2 (Oct 9) 808-810
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