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Natural childbirth V:
epidural side effects and risks
by CHRIS KRESSER 83 comments
Before we dive into a discussion of epidural analgesia I’d
like to clarify my intention in writing this series in light of
some of the comments on previous articles.
The purpose of this series on natural childbirth is to
demonstrate that homebirth is as safe – if not safer – than
hospital birth for low risk pregnancies, and that medical
interventions commonly used in hospital births such as
epidurals, induction with synthetic oxytocin and cesarean
sections have risks and complications that are often not
communicated to pregnant women.
Currently fewer than 1% of births happen at home in the
U.S., and I believe this is largely due to misconceptions
about its safety. My intention here is to correct those
misconceptions.
The purpose of this series is not to condemn the use of
these interventions in all circumstances. All of them have
their place, and can be very helpful and even life-saving
(for mothers and babies) when used appropriately. In fact, I
said the following in bold text at the end of the first article
in this series:
I want to be clear: no matter where birth
takes place, complications may arise that
require medical intervention and I am
100% in support of it in these cases.
There is still much we don’t understand about birth, and
even more we don’t have direct control over. In some
cases, despite a woman’s best efforts to have a natural,
undisturbed birth, complications arise that require medical
attention (and transfer to a hospital if she started laboring at
home). In these circumstances, I absolutely endorse taking
advantage of whatever interventions may protect the health
and safety of both the mother and baby. At the end of the
day, that is far, far more important than the method by
which the baby was born.
I also want to be clear that I am not judging women who
choose to have hospital births, receive epidurals, induce
with Pitocin or end up having a cesarean section. I respect
the right of women to choose a method of childbirth that
feels safe and comfortable for them.
My purpose, instead, is to tell the side of the story that
women are often not told, and to raise awareness of the
risks associated with these procedures so that when it
comes time to make their own decision, women are
adequately educated and informed to do so.
What is an epidural and how common
are they?
Dr. Leonard J. Corning, a neurologist in New York, was the
first physician to use an epidural. In 1885 he injected
cocaine into the back of a patient suffering from spinal
weakness and seminal incontinence.
Today, epidurals are by far the most popular method of
pain relief during labor in U.S. hospitals. According to the
Listening to Mothers II survey (2006), more than 75
percent of women reported that they received an epidural,
including 71 percent of women who had a vaginal birth. In
Canada in 2005-2006, 54 percent of women who gave birth
vaginally used an epidural, and during those same years in
England, 22 percent of women overall had an epidural
before or during delivery.
In an epidural, a local anesthetic – still derived from
cocaine – is injected into the epidural space (the space
around the tough coverings that protect the spinal cord).
Epidurals block nerve signals from both the sensory and
motor nerves, which provides effective pain relief but
immobilizes the lower part of the recipient’s body.
In the last decade, a new type of epidural has been
developed (called “walking epidurals”) that reduce the
motor block and allow some mobility.
Spinal analgesia (a.k.a. “spinals”) are also used for pain
relief during labor, but unlike conventional epidurals, they
allow women to move during labor. In a spinal, the
analgesic drug is injected directly into the spinal space
through the dura, producing fast-acting, short-term pain
relief.
Epidurals have significant impacts on
all hormones of labor
In the last article, Natural Childbirth IV: The Hormones
of Birth, we discussed the exquisite orchestration of
hormones during birth and the risks of interfering with the
body’s natural hormone regulation.
Unfortunately, epidurals interfere with all of the hormones
we discussed.
They inhibit beta-endorphin production, which in turn
shuts down the shift in consciousness (“going to another
planet”) that characterizes undisturbed birth.
Epidurals reduce oxytocin production or keep it from
rising during labor. They also blunt the oxytocin peak that
would otherwise occur at the time of birth because the
stretching receptors of a woman’s lower vagina (which
trigger the peak) are numbed.
As Dr. Sarah Buckley explains 1:
A woman laboring with an epidural
therefore misses out on the final
powerful contractions of labor and must
use her own effort, often against gravity,
to compensate for this loss. This explains
the increased length of the second stage
of labor and the increased need for
forceps when an epidural is used.
Epidurals have also been shown to inhibit catecholamine
(CA) production. Remember that CA can slow or stop
labor in the early stages, but it promotes the fetus ejection
reflex in the second stage of labor. Thus inhibiting CA
production may make delivery more difficult.
Epidurals limit release of prostaglandin F2 alpha, a lipid
compound that stimulates uterine contractions and is
thought to be involved with the initiation of labor.
Prostaglandin F2 alpha levels should naturally rise during
an undisturbed labor. However, in one study women with
epidurals experienced a decrease in PGF2 alpha and a
consequent increase in labor times from 4.7 to 7.8 hours.
Epidurals interfere with labor and
have side effects for mothers
Epidurals have been shown to have the following effects on
labor and laboring mothers:
• They lengthen labor.
• They triple the risk of severe perineal tear.
• They may increase the risk of cesarean section by 2.5
times.
• They triple the occurrence of induction with synthetic
oxytocin (Pitocin).
• They quadruple the chances a baby will be persistently
posterior (POP, face up) in the final stages of labor,
which in turn decreases the chances of spontaneous
vaginal birth (see below).
• They decrease the chances of spontaneous vaginal
delivery. In 6 of 9 studies reviewed in one analysis,
less than half of women who received an epidural had
a spontaneous vaginal delivery.
• They increase the chances of complications from
instrumental delivery. When women with an
epidural had a forceps delivery, the amount of force
used by the clinician was almost double that used
when an epidural was not in place. This is significant
because instrumental deliveries can increase the short-
term risks of bruising, facial injuries, displacement of
skull bones and blood clots in the scalp for babies, and
of episiotomy and tears to the vagina and perineum in
mothers.
• They increase the risk of pelvic floor problems
(urinary, anal and sexual disorders) in mothers after
birth, which rarely resolve spontaneously.
One important thing to note about these studies: in most of
them, the women in the “control” groups were given opiate
painkillers, which are also known to disrupt the natural
hormonal processes of birth. We can assume, then, that a
comparison of women using no drugs during labor would
have revealed even more substantial differences.
Epidural also have side effects for
babies
It’s important to understand that drugs administered by
epidural enter the baby’s bloodstream at equal and
sometimes even higher levels than those present in the
mother’s bloodstream.
However, because babies’ immune systems are immature,
it takes longer for them to eliminate epidural drugs. For
example, the half-life of bupivacaine, a commonly used
epidural analgesic, is 2.7 hours in an adult but close to 8
hours in a newborn. 2
Studies have found detectable amounts of bupivacain
metabolites in the urine of exposed newborns for 36 hours
following spinal anesthesia for cesarians.
Some studies have found deficits in newborn abilities that
are consistent with the known toxicity of drugs used in
epidurals.
Other studies have found that local anesthetics used in
epidurals may adversely effect the newborn immune
system, possibly by activating the stress response.
There is evidence that epidurals can compromise fetal
blood and oxygen supply, probably via the decrease in
maternal blood pressure that epidurals are known to
cause.
Epidurals have been shown to cause fetal bradycardia, a
decrease in the fetal heart rate (FHR). This is probably
secondary to the decrease in maternal CA caused by
epidurals which in turn leads to low blood pressure and
uterine hyper-stimulation.
Epidurals can cause maternal fever, which in turn may
affect the baby. In a large study of first-time moms, babies
born to mothers with fever (97% of whom had epidurals)
were more likely to be in poor condition (low APGAR
scores) at birth, to have poor tone, to require resuscitation
and to have seizures in the newborn period, compared to
babies born to mothers without fever.
Older studies using the more exacting Brazelton Neonatal
Behavioral Assessment Scale (NBAS, devised by
pediatricians) rather than the newer, highly criticized
Neurologic and Adaptive Capacity Score (NACS, devised
by anesthesiologists – can you say “conflict of interest”?)
found significant neurobehavioral effects in babies exposed
to epidurals.
In one such study, researchers found less alertness and
ability to orient, and less mature motor abilities, for the
first month of life. These findings were in proportion to the
dose of bupivacaine administered, suggesting a doserelated response.
Epidurals may interfere with motherbaby bonding and breastfeeding
Some studies suggest that epidurals may interfere with the
normal bonding that occurs between mothers and babies
just after birth.
In one study, mothers given epidurals spent less time with
their babies in the hospital. The higher doses of drugs
they received, the less time they spent.
In another study, mothers who had epidurals described their
babies as more difficult to care for one month later than
mothers who hadn’t had an epidural.
It’s important to note that neither of these studies prove that
epidurals were the cause of the behavioral changes
observed. However, if epidurals were at fault, the effects
are most likely caused by their interference with the natural
orchestration of hormones we discussed in the previous
post, and may also be influenced by drug toxicity and the
complications associated with epidural births: long labors,
forceps and cesareans.
There is also evidence that epidurals may decrease
breastfeeding efficiency.
In one study, researchers used the Infant Breastfeeding
Assessment Tool (IBFAT) and found scores highest
amongst unmedicated babies, lower for babies exposed to
epidurals and IV opiates, and lowest for babies exposed to
both.
A large prospective study found that women who had used
epidurals were more than 2 times as likely to have
stopped breastfeeding by 24 weeks compared with
women who used non-pharmacological pain relief.
Conclusion
Epidural analgesia is a highly effective form of pain relief
and a useful intervention in certain circumstances.
However, epidurals and spinals also cause unintended side
effects in both the mother and baby, and interfere with the
natural birth process and bonding between mother & baby.
In some cases epidurals may be beneficial, but the evidence
suggests that they should not be used as routinely as they
currently are in the U.S. and other industrialized countries.
Articles in this series:
• Natural childbirth I: is homebirth more dangerous
than hospital birth?
• Natural childbirth IIa: is ultrasound necessary and
effective during pregnancy?
• Natural childbirth IIb: ultrasound not as safe as
commonly thought
• Natural childbirth III: why undisturbed birth?
• Natural childbirth IV: the hormones of birth
• Natural childbirth V: epidural side effects and risks
• Natural childbirth VI: Pitocin side effects and risks
• Natural childbirth VII: Cesarean risks and
complications
1.
2.
Buckley S. Gentle birth, gentle mothering: a doctor’s
guide to natural childbirth and early parenting choices.
Celestial Arts 2009. pp.117 ↩
Hale TW. Medications and Mother’s Milk. 12.
Amarillo, TX: Hale Publishing; 2006. ↩