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Is the Clinical Efficacy of Epidural Analgesia During Childbirth Justifying its
Predominance?
Honors Conference Presentation 2014
Marissa Labate
Mentor:
Jeanne Maiden, Ph.D., RN, CNS-BC
Committee Member:
Carrie Black, MSN, RN
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TABLE OF CONTENTS
Abstract……………………………………………………………………………………3
Chapter One: Introduction………………………………………………………………...4
Chapter Two: Definition…………………………………………………………………..4
Chapter Three: History, Benefits and Risks of Epidural Analgesia………………………5
Chapter Four: Physician and Nursing Perspectives…………………...…………………..8
Chapter Five: Nursing Implications, Summary, and Recommendations for Future
Research………………………………………………………………………….………10
References………………………………………………………………………………..15
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Abstract
The past several decades have revealed significantly increased and widespread use of
epidural analgesia during childbirth compared to the natural option. Continuous debate
exists regarding the safety and efficacy of epidural analgesia, as well as the rationale for
its predominance in clinical practice. My project aims to determine whether this rising
trend is due to objective clinical evidence, subjective clinician preference, or socially
influenced patient decisions.
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Chapter One: Introduction
In the year 2012, the number of births in the United States totaled 3,952,937
(Hamiliton, Martin & Ventura, 2013). Labor and childbirth can be a wonderful and life
changing event, yet it can be a very painful experience. Pain relief options range from
natural options such as breathing techniques to nerve-blocking epidural analgesia.
Epidural analgesia is a growing choice as pain management for labor and delivery. The
use of epidural analgesia in the United States tripled from 1981 to 2001 (Silva & Halpern,
2010). According to the Centers for Disease Control (CDC), the rate of epidural use
during childbirth was approximately sixty-one percent for vaginal deliveries (Osterman &
Martin, 2011). However an ongoing debate regarding the safety, efficacy, and results of
using epidural analgesia for pain management exists. Nevertheless, their availability and
popularity has increased in hospitals, and the demand for this option of pain relief has
risen from patients (Stark, 2003). The interest in epidural analgesia as a choice of pain
relief during childbirth has provoked an exploration of what has led to this option. The
purpose of this paper is to determine whether this rising trend is due to objective clinical
evidence, subjective clinician preference, or socially influenced patient decisions.
Chapter Two: Definition
Epidural analgesia is a form of pain management in which a catheter is inserted into
the epidural space of the spine. The spine is composed of bones (vertebrae) separated by
intervertebral disks. These disks are composed of cartilage, collagen fibers, and water
(Marieb & Hoehn, 2010). Once the skin has been numbed, the epidural needle is placed
between the lumbar vertebrae reaching the epidural space. The epidural space is outside
of the spinal column, which contains the spinal nerves and cerebrospinal fluid (“Epidural
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analgesia for labor and delivery”). Understanding the anatomy of the spine allows for
better visualization of where epidurals are placed. When the catheter is inserted into the
epidural space, medication is given through the catheter that blocks nerve impulses from
the lower spine. Commonly, epidurals contain a class of medications known as local
anesthetics, such as bupivacaine or lidocaine. Local anesthetics are combined with opiods
or narcotics like fentanyl or morphine for example. Injection of these medications leads
to decreased painful impulse transmission to the lower body. The purpose of a epidural is
to provide pain relief (analgesia) rather than a total lack of feeling (anesthesia). Typically,
epidurals are placed when the woman is in active labor, and when the cervix is dilated
four to five centimeters. Epidural analgesia can be administered by an Anesthesiologist,
an Obstetrician, or a Certified Registered Nurse Anesthetist (CRNA). All three of these
healthcare providers receive additional training and competency education to administer
epidurals. (American Pregnancy Association).
Chapter Three: History, Benefits and Risks of Epidural Analgesia
Epidurals first originated in the early 1900s but became popular for labor and delivery
in the 1940s. During this time, they were used very rarely as a method of pain relief for
childbirth. It was only in the 1970s that epidurals gained widespread popularity (“The
History of…”). Major changes were occurring during this time period: childbirth was
transitioning from the home to the hospital, and feminism became prominent. With more
deliveries occurring in the hospital, epidurals were used more frequently. Additionally, a
rise in feminism led to women desiring improvements in healthcare, specifically
childbirth (“A Quick History…”).
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Within the past twenty years, epidural placement has changed from injecting into the
sacral area of the spine to the lumbar portion of the spine. The change was made to
reduce risks associated with injecting into the sacral area, such as difficult insertion and
accidental injection into the baby’s head. An increase of epidurals in the 1970s was due
to technological advances for childbirth, such as fetal heart monitoring. With newer
technology, doctors were more comfortable treating any side effects caused by the
epidural. Epidurals were then recommended more by practitioners, and this ultimately led
to further popularity from women requesting them as word spread (“The History of
Epidurals”).
The history of epidurals additionally included factors that led to their increased use
and greater acceptance. The medication oxytocin was discovered and used to augment
labor. Oxytocin is administered when contractions slow or stop because of the epidural.
With the discovery of Oxytocin, it was easier to manage contractions, and therefore
epidurals were encouraged more frequently. Another cause for epidurals gaining
popularity was the improved safety and use of Caesarean sections. If there were
complications caused by the epidural or the oxytocin, doctors felt more confident in
performing a caesarean section. Continuous fetal monitoring also led to the rise in
epidural use. Fetal monitoring allows caregivers to identify any distress to the baby
caused by epidurals or oxytocin. As a result, caregivers were more comfortable with
epidurals. Lastly, word of mouth spread about epidurals, and women began to request
them for labor more frequently (“The History of Epidurals”).
Similar to other invasive pain relieving interventions, epidural analgesia involves risk
to the mother and baby. However, there are several benefits that are worthy to note.
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Epidural analgesia can provide a woman a very positive birthing experience. An epidural
can enable the mother to relax and focus on being actively involved in the birth. Most
importantly, epidurals effectively provide pain relief from the discomfort of labor and
delivery (American Pregnancy Association).
As epidural analgesia can be very beneficial to labor and delivery, there are also
several risks to the mother and baby. Some of these risks include a drop in maternal
blood pressure (hypotension), maternal fever, and prolonged labor (Stark, 2003).
Additionally, epidurals can create difficulty during the pushing phase of labor, which
may lead to interventions such as the use of the medication Pitocin, use of forceps,
vacuum extraction, or a cesarean delivery. Forceps are an instrument used to assist
delivery by gripping the baby’s head (Ross, 2011). A vacuum extraction also assists in
difficult deliveries by attaching a cup and vacuum pump to the baby’s head (“Vacuum
Extraction”). Rarely experienced side effects of epidural analgesia are severe headaches
due to spinal fluid leakage, however they affect less than one percent of women
(American Pregnancy Association). Additional common side effects include shivering,
ringing of the ears, backache, soreness at needle insertion site, nausea, and difficulty
urinating. Numbness of the lower body can also occur a few hours after childbirth, so
walking may require assistance (American Pregnancy Association). Epidural analgesia
may possibly cause the baby in-utero to have trouble moving into position for delivery, as
narcotic medications used in the epidural may make the baby lethargic. The drowsiness
can result in breastfeeding obstacles, or difficulty latching on within the first forty-eight
hours (Stark, 2003). Epidurals cause the pelvic floor muscles to relax, additionally
affecting the position of the baby. These muscles normally assist the baby in descending
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into the correct position for delivery. As a result, the relaxation of the pelvic floor
muscles can cause the baby to move into sub-optimal positions, which can eventually
lead to less efficient contractions, resulting in prolonged labor (Cohain, 2010). The baby
can also have additional side effects caused by epidural analgesia. These include
respiratory depression, an increase in fetal heart rate variability, or fetal malpositioning.
Consequently, the risk for instrumental delivery and episiotomy is increased with
epidural analgesia. In rare circumstances, permanent nerve damage may occur in the area
of catheter insertion (American Pregnancy Association).
Chapter Four: Physician and Nursing Perspectives
Physicians demonstrate a different opinion with regard to epidural analgesia. The
American Congress of Obstetricians and Gynecologists (ACOG) and the American
Society of Anesthesiologists state that “There is no other circumstance in which it is
considered acceptable for a person to experience untreated severe pain, amenable to safe
intervention, while under a physician’s care” (“Pain Relief During Labor”). Grant (2011)
defends this position. Grant (2011) believes that not offering sufficient pain relief is
inhumane. Grant also believes that there are many women who initially want no
medication, and eventually request medication after feeling the unbearable pain.
According to Grant (2011), pain should be prevented, and treatment should be provided
before pain begins. As an example, a dentist does not wait to inject Novocain until pain is
felt. Grant (2011) reported that pain relief could safely result from epidurals. In addition,
Grant (2011) provided more support of epidural use by explaining the risks of not
choosing to receive an epidural. Unrelieved pain throughout labor and post-partum can
trigger stress responses that can possibly lower the baby’s oxygen supply, hinder breast-
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feeding, and increase the possibility of developing chronic pain conditions. Additionally,
untreated pain can increase the chance of post-partum depression as well as posttraumatic stress disorder (PTSD). Grant (2011) does not deny that epidurals can produce
adverse effects. He explains these, and compares them to adverse effects of different
pain-relief methods and the effects of unrelieved pain (Grant, 2011).
Interestingly, a study completed by Klein, et al., (2001) discovered that family
physician attendance at birth varied by the percentage of epidurals given. Subsequently,
physicians who gave low percentages of epidurals were found to spend more time with
their patients, despite these patients spending less time in the hospital. Those physicians
who prescribed higher numbers of epidurals had patients who spent more time in the
hospital, and less time with their physician (Klein et al., 2001).
Epidurals can be administered by anesthesiologists, obstetricians, and Certified
Registered Nurse Anesthetists (CRNAs). Healthcare provider perspectives regarding
epidurals are worthy to note, as they vary among discipline (American Pregnancy
Association). Additionally, certified nurse midwives (CNMs) play an important role in
labor and delivery when involved. Typically offering more holistic methods for comfort
compared to technological options for childbirth, CNMs tend to have a negative opinion
concerning the increase of epidural use in CNM practice (Stark, 2003). Fifty-three
percent of 1,605 CNMs expressed a negative attitude regarding epidurals in a nationwide
survey, and sixty-four percent voiced concern regarding the rising demand for epidural
analgesia. Additionally, fifty-nine percent of CNMs surveyed believed “their
marketability as providers of maternity care was related to providing epidurals” (Stark,
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2003). This survey implied that although CNMs express concern regarding epidurals,
there is an increasing pressure for this analgesia to be used during labor (Stark, 2003).
Cohain (2010) justified her personal perspective of epidural analgesia in the journal
Midwifery Today. She explained that labor pain was not continuous, that there is about
thirty seconds of pain with contractions followed by two to four minute intervals without
pain. Cohain stated that if one needs pain relief, acetaminophen is a suitable option. She
believes that when a mother goes through labor without an epidural, she gains the selfconfidence that is necessary for mothering (Cohain, 2010). This attained strength aids
with the challenges of being a mother. Cohain (2010) also stated that the risks of
epidurals are not properly or thoroughly explained to patients. She goes further into detail
regarding one of these risks: breastfeeding difficulties. Cohain (2010) explained that
epidural analgesia in combination with Oxytocin causes the mother to have lower
prolactin and oxytocin levels as a reaction to breastfeeding, resulting in a decrease in
milk production. Cohain concluded that with an empowered mother who labored without
an epidural, the baby entered the world with a successful breastfeed and a mother to care
for it with a newfound strength (Cohain, 2010).
Chapter Five: Nursing Implications, Summary, and Recommendations for Future
Research
The rise in epidural use creates several implications for nurses. “Nurses are the
frontline providers of birth care in the US for most women…nurses…probably hold the
great potential to influence the culture of birth” (Kennedy & Lyndon, 2008, p. 434).
Therefore, nurses have a major impact on women’s decisions regarding childbirth, and
they should provide education so patients can make informed decisions. Collaboration
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between the nurse and the patient will allow women to feel more involved in their
birthing process. In a study completed by Hidaka and Callister, (2012) it was determined
that women were not given sufficient information regarding epidural analgesia before it
was administered. These women felt that they did not know the risks or the benefits of
epidural analgesia before choosing to receive an epidural (Hidaka & Callister, 2012). It is
the duty of the nurse and physician to provide education and explanations regarding
epidural analgesia as well as other pain relief options as patient advocates (2012). In
addition, no matter what women choose as their method of pain relief, nurses should
support their choice. This support contributes to the woman’s well being in the labor and
childbirth experience.
Interestingly, Hidaka and Callister (2012) discovered that nurses’ intentions to deliver
continuous labor support were lower for the patients utilizing epidural analgesia (Hidaka
& Callister, 2012). Labor and delivery nurses recognized barriers to providing supportive
care for laboring women. Barriers to labor support included a lack of skills in assisting
these women to cope without the use of medication. Participants in the study explained
that they may have opted to use a different method of pain management had their nurses
supported other types of pain management such as walking or practicing focused
breathing (Hidaka & Callister, 2012). Literature demonstrates nurse support education
and information on offering coping mechanisms as well as providing natural methods of
pain relief. A recommendation of the study supported labor support certification for
nurses to enrich the mother’s birth experience. Additionally, nurses should be asking
questions on how the woman is coping with labor, and offering a variety of approaches
for pain management. If the woman opts to receive an epidural, nurses should question
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how and if it is helping the patient. Flemming, Smart, and Eide (2011) supported
advocacy and encouragement during labor. These women described the significance of
nurses creating a trusting and supportive environment. This reassurance from nurses was
helpful, instead of trusting in childbirth technology for delivery of care (Flemming,
Smart, & Eide, 2011).
Nurses must prioritize explaining the risks and benefits of epidural analgesia in
addition to physicians obtaining informed consent. In a study by Hidaka and Callister
(2012), all of the women were anxious before receiving epidurals. Some explained that
they did not know the side effects while others stated they were misinformed (Hidaka &
Callister, 2012). The timing of education is very important. Nurses need to provide
thorough education before labor begins, or early in labor. As labor progresses, the pain
and vulnerability can push women to choose epidurals without sufficient information
(Hidaka & Callister, 2012). It cannot be overemphasized that nurses are a vital link in
influencing women’s childbirth decisions. It is crucial for nurses to understand how
women experience their childbirth process, and what influences affect their perception of
childbirth.
Some of these influences include what women see or hear in the media.
Representations of childbirth in the media may not be realistic or based on evidencebased practice. Nurses can help educate women regarding childbirth as depicted in
movies and television shows (Hidaka & Callister, 2012). Additionally, ninety-seven
percent of women in one study from twenty-four countries utilized the Internet for
education and decision-making throughout pregnancy. Ninety-four percent used the
Internet to confirm information provided to them by healthcare providers (Lagan,
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Sinclair, & Kernohan, 2010). Nurses could possibly help women by providing examples
of quality sources of online information, in addition to interpreting and demonstrating
application of that information. The media today is prominent and influential. Hidaka and
Callister’s (2012) study reported that media representations of labor and delivery swayed
participants to change their mind from initially desiring a natural childbirth to planning to
receive an epidural before going into labor.
Summary and Recommendations for Future Research
More than half of women giving birth in the United States utilize epidural analgesia as
a method of pain relief (Osterman & Martin, 2011). Demand for epidural analgesia has
increased. Various influences contribute to this growing demand, such as word of mouth,
media, and healthcare provider perspectives (Hidaka & Callister, 2012; “The History
of…”). Physicians demonstrate a preference toward utilizing epidural analgesia, while
Certified Nurse Midwives object to the increasing demand of this unnecessary
intervention, in their perspective (Grant, 2011; Cohain, 2010; Stark, 2003; Klein et al.,
2001). According to the literature, patients demonstrated overall satisfaction with
epidural analgesia during childbirth (Hidaka & Callister, 2012). Continued improvement
is needed in the area of education at a time that is ideal for the patient (2012).
Recommendations for future research should focus on which methods of education work
best and what time frame that education should be given. The literature demonstrates
evidence confirmed by physicians, nurses, and patients alike that epidural analgesia is
considered a safe and efficient method of pain relief for childbirth.
The healthcare landscape in the United States is rapidly changing. Clinicians and
administrators alike are constantly challenged to seek efficient, cost effective, and safe
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utilization of healthcare resources. Registered Nurses have long demonstrated a
significant role in the childbirth process demonstrating superior epidural knowledge.
Further opportunity exists for the Registered Nurse to pursue advanced practice roles in
the administration of epidural anesthesia such as Certified Registered Nurse Anesthetists
(CRNA's). Registered Nurses must recognize their expertise and value in the healthcare
setting and should strive to practice at their highest level of competency and certification
(American Nurses Association). This philosophy ultimately should result in effectively
helping to meet our nation’s healthcare needs, enhancing an integrated medical team, and
improving overall patient outcomes (“Health Care Reform…”).
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