There are lots of good things to say about epidurals. They can completely take away the painful sensations of labour contractions while allowing the mother to be awake and aware for the birth. Recovery from a Caesarean is generally much easier for moms who have epidurals than those who have a general anaesthetic. Finally, the epidural doesn’t affect a newborn baby’s breathing in the way that other medications given during labour and birth do.
For some women, an epidural can make a very positive difference. Cori Jones* remembers, “I was induced, and labour was very, very painful, so I got an epidural. I was totally amazed that within minutes I was pain-free and I was able to rest, relax and dilate.”
No wonder they’re so popular.
Epidurals work well for the majority of mothers and babies. But like any other intervention, epidurals have potential, and proven, risks and side effects — which aren’t as widely known as the benefits. What do you need to know to make an informed decision about using epidural anaesthesia?
First, it’s worth noting that much of the research on epidurals has been inconclusive or even contradictory, making it hard to know for sure what the risks are. That’s because the studies have not all measured the same things. For example, some compare the epidural to another form of labour pain relief, while others compare women receiving the epidural to women receiving no medication. Different medications can be used in the epidural itself, yielding different results, and the length of time a woman receives the medication varies. Here’s what the research says.
*Name changed by request.
In 2002 the American Journal of Obstetrics and Gynecology published two different analyses of past research aimed at identifying any effect epidurals might have on labour. Both studies found:
• Longer labour Epidurals possibly increase the length of first stage labour (according to a subsequent 2005 study, by about 20% on average) and definitely increase the length of the second stage (pushing the baby out) by about 50%.
• Higher rates of augmentation of labour (induction) and of Caesarean section With an epidural, you are more likely to need oxytocin to speed up labour. (About 20% of women, on average, need this intervention, compared to 10% who do not have epidurals.) Epidurals may also increase the risk of Caesarean section, especially if given early in labour. The risk is higher for women who are overweight or obese.
• More forceps deliveries, tears and episiotomies Epidurals increase the risk of needing forceps or a vacuum extractor to deliver the baby. (In a 1998 study, about 10 times as many forceps deliveries were seen with epidurals; a 2006 study found the rate was nearly eight times higher.) They also increase the risk of third- and fourth-degree (more serious) lacerations to the perineum.
• Fetal distress Epidurals may increase the risk of rapid heartbeat in the baby before birth, a sign of fetal distress.
Previous studies have found that when the mother has an epidural, her baby is more likely to be in a difficult position at birth (facing toward her pubic bone rather than her back, or “occiput posterior,” for example). Some researchers thought this might be because mothers with babies in these more difficult positions were more likely to ask for an epidural. But a 2005 study in Boston disproved this theory. The researchers did ultrasounds when women first arrived at the hospital in labour, then repeated them throughout their labour. Before any anaesthetic was given, the women who requested an epidural had the same number of posterior babies as the women who didn’t. However, by the time they delivered, the epidural group had 12.9% posterior babies, compared to 3.3% in the non-epidural group. This may at least partially explain the longer second stage and the increase in forceps, vacuum extractor and Caesarean sections for women who have had epidurals.
The 2002 studies also identified some risks for women receiving the epidural during labour:
• Increased risk of running a fever A 1997 study found that about 15% of women getting epidurals had a fever; for longer labours this went up to 36%. (Only 3% of women without epidurals had a fever.) Another study found that when mothers had this epidural-related fever, 23% of the babies had low Apgar scores, and 11.5% needed resuscitation (compared to 1% of the babies whose mothers did not have epidurals).
• Increased risk of a drop in blood pressure This is a very common side effect: A 2000 study from Belgium reported it in 58% of mothers.
Heather Drewett’s doctor wanted her to wait a bit before pushing because her baby was in the posterior position. “They topped up the epidural so I wouldn’t feel the urge to push,” Drewett recalls. “That sent my blood pressure plummeting. I was nauseous and dizzy and very faint. So they turned off the epidural and flushed my system with saline — it was really an ordeal. When my daughter was finally born, she was very, very sleepy. She slept most of the first couple of days and lost quite a bit of weight.”
• Increased risk of urinary incontinence in the postpartum weeks A 1993 study from Denmark found that about 27% of women who had epidurals experienced stress incontinence during the first three months after giving birth, compared to about 13% of women who had vaginal births without epidurals.
• In some very rare cases, epidurals can cause life-threatening complications A 2005 study from Britain reported that the incidence of some of these ranged from 1 in 2,900 to 1 in 16,200.
Some side effects are described by researchers as “minor,” but Henci Goer, author of The Thinking Woman’s Guide to a Better Birth, points out that they can still create a lot of difficulty for the mother who is trying to care for a newborn. These include:
• Severe headaches In some cases, these require a return to the hospital for treatment.
• Problems with urination A 2006 study found that 83% of women getting epidurals in labour needed catheterization during labour; both having a catheter and having a longer labour were risk factors for postpartum urination difficulties.
• Numbness and weakness in the legs and feet
For most women, these effects are short-lived, but Samantha Leeson recalls: “After having the epidural, it took me two full weeks to regain complete sensation in my legs. I had trouble lifting them and couldn’t safely climb the stairs that whole time.”
While Jones was pleased with how the epidural helped her during labour, she also describes feeling emotionally detached from her newborn: “After my baby was born, I didn’t even feel like I was his mother — I truly believe that this was because I didn’t feel him come out, so it wasn’t really real. I also think this got in the way of the bonding process. I didn’t hold him much, and he didn’t nurse as often as he should have.”
Andrea Chute says that when her son Zack was born (after she’d had an epidural for about six hours) “he really didn’t root, he just sort of nuzzled. I tried to latch him on, but he half-heartedly suckled a few times and then dozed against my breast. I needed to keep waking him up to try to get him to feed. It wasn’t until after three weeks that he “woke up” and started nursing better and giving cues that he wanted to nurse. When my daughter was born without medication, it was a really different experience — her alertness right from birth and her ability to latch and nurse were amazing.”
“The medication given in the epidural can be found and measured in the umbilical cord, and the concentration goes up with the length of time the epidural is given,” says Goer. The biggest impact of that medication seems to be on breastfeeding. How much the baby is affected depends, in part, on how long the mother has the epidural and what medications are used by the anaesthetist. Lactation consultant Linda J. Smith, who is the co-author of Impact of Birthing Practices on Breastfeeding, says evidence on this issue has been accumulating since 1995.
• Problems with the latch “We know that healthy newborn babies are able to find the nipple and latch on with minimal help,” explains Smith. “But after an epidural, the baby often appears disoriented and isn’t able to find the nipple or latch well. Researchers have observed that the mother may be able to get the baby to latch, but the baby doesn’t seem to know what to do. He may not suck at all, or the suck may be disorganized and not effective at getting milk.”
• Edema and engorgement Overly full (engorged) breasts make it harder for a baby to latch on. Smith observes that the intravenous fluids given to mothers when they have an epidural (to counteract the potential drop in blood pressure) tend to accumulate in the breasts (edema). The synthetic oxytocin often needed to speed up labour when an epidural is in place also causes the body to retain more fluid. “When the mother’s breasts become painfully full a couple of days after the birth, a significant part of that fullness in some women, especially around the areola, is fluid, rather than milk,” she explains. “That makes it very difficult for the baby to latch and feed well.”
• Low milk supply These early difficulties in breastfeeding can lead to a low milk supply because it is the regular, frequent removal of milk in the early days that prepares the breasts to make more milk. If the baby doesn’t nurse well and the milk isn’t expressed, the breasts respond by making less milk — and this often leads to supplementation and weaning.
These breastfeeding problems can lead to supplementation and early weaning. A 2003 study in Finland found that 67% of the mothers who had epidurals were supplementing their babies’ feedings with infant formula during the first 12 weeks, while only 29% of the mothers who had not had epidurals were supplementing. A study in Australia in 2003 found that while nearly 80% of the mothers who did not have an epidural were still breastfeeding at two months, only 60% of those who had epidurals breastfed that long.
Breastfeeding difficulties can create other problems for the baby. Samantha Leeson says: “Fergus didn’t latch for more than 12 hours, and therefore went without food for a long time, and I think that was a major contributing factor in the level of jaundice he developed.”
So what does all this mean for the expectant parent?
If you do opt for the epidural, be aware of and plan ahead for possible problems.
• Be well prepared with other strategies for coping with pain in labour. Many potential side effects seem to be “dose-related” — so delaying as long as possible can minimize the effects of the epidural on labour and on breastfeeding. You may even find that labour is not as difficult as you’d had expected and that these coping strategies are all you need.
• Find a good source of breastfeeding help ahead of time — a lactation consultant or La Leche League leader. If the baby does have a hard time learning to latch, that extra support will be very valuable. Know where to rent or buy a pump in case you need it to establish your milk supply.
• Line up extra help for the postpartum period. You’ll want to be able to focus on getting breastfeeding going and recovering from the birth.
Not planning to have an epidural? It’s good to prepare for the possibility anyway because you may change your mind or have a situation arise where an epidural is the best option.
As with so many other decisions, it’s a matter of weighing the risks and benefits — which are unique for each mother, each baby and each labour. When you know all sides of the story, you can choose the best option for you and your baby.