Epidural during Labor: Epidural Complications and Controversies

Note: While the author is a physician anesthesiologist, nothing contained in this article should be used as a substitute for discussion with your own doctor. This site is for informational purposes only and does not constitute medical diagnosis or ad
Note: While the author is a physician anesthesiologist, nothing contained in this article should be used as a substitute for discussion with your own doctor. This site is for informational purposes only and does not constitute medical diagnosis or ad | Source

What is an Epidural?

Religion, politics and labor epidurals...three topics that are guaranteed to start heated debates when the subjects come up.


While many women get epidurals for labor, there are some very vocal individuals and groups who seem to equate epidurals with attempted murder of their offspring.

Epidurals cause changes to the body, no doubt. There are even some potential issues with labor, delivery, the newborn, breastfeeding.... but those who distort or exaggerate the risks are doing a disservice to those who could be helped by an epidural.

HOW MANY WOMEN GET EPIDURALS?

Epidural analgesia (pain relief) is used frequently during labor and delivery, with over 50 percent of women receiving this type of labor pain relief in the United States. There is much variability in the epidural rate around the country due to a variety of factors, with some states reporting an epidural (or combined spinal/epidrual) rate of nearly 80 percent.

An epidural is placed into the small epidural space outside of sac that surrounds the spinal cord and spinal fluid.Usually, a catheter-- but not a needle-- as is sometimes feared, is left in place in the epidural space so that medicine can be given continuously or can be increased or decreased as needed.

Source

Personal Note from the Author

Let me start by saying here and now, I am an anesthesiologist. I have placed thousands of epidurals. BUT, but, I have never talked anybody into one, I have never withheld information or refused to answer questions before or after the procedure. I am not part of some giant conspiracy to push epidurals or force interventions on women. I'm not selling anything. That said, I will not approve comment below that amount to a personal attack because of my profession. Thank you.

And yes, I have been directly or indirectly accused of these things without provocation when these very vocal and aggressive detractors find out I'm an anesthesiologist.

Epidural Controversies

There are many controversies related to epidural anesthesia during labor and delivery. The most common ones will be discussed here.

The choice to have an epidural is a personal one. Every woman who faces this decision deserves to be able to make it as an 'informed consumer'. This isn't necessarily easy as there is A LOT of misinformation and outright fallacy at the fingertips of every mom-to-be.

There are also some good, reliable sources of information. The problem is that it's hard to know which is which sometimes.

Epidural Catheter and Needle

An epidural catheter is shown (middle) next to an epidural (Tuohy) needle to its right.
An epidural catheter is shown (middle) next to an epidural (Tuohy) needle to its right. | Source

Epidural Catheter in Place

Epidural catheter in place in a laboring woman. The orange circle is the sterilizing soap that is used (betadine) before starting the procedure.
Epidural catheter in place in a laboring woman. The orange circle is the sterilizing soap that is used (betadine) before starting the procedure. | Source

Epidural Risks

There are naturally, some risks of epidural anesthesia. After all, a needle is used to inject medication that, then, changes the workings of your body. It would be unrealistic to expect there to NOT be risk. However, understanding the risks and complications and their real likelihood is the best way to make an informed decision about receiving an epidural in labor.

Risks are undesired effects that may or may not happen, may or may not cause harm and may or may not be avoidable. These are just examples and are not meant to represent a comprehensive list of all risks that could have or ever have occurred.

  • Any time a needle is used for a procedure, the risks of bleeding and infection exist. These occur rarely (1 in 200,000 cases), but can have devastating consequences, such as paralysis.
  • An epidural, unlike a spinal, does not involve entering the space that contains the CSF. If the dura (covering over the spinal cord and fluid) is punctured unintentionally, a spinal headache can occur. The risk is less than 1 percent.
  • There is a small risk of nerve injury or prolonged pain related to nerve irritation. The reasons for this are not entirely clear. This is actually also pretty rare. Many times that an epidural is blamed for nerve injury or back pain, special nerve/muscle studies will show that it is related to injury during labor and delivery rather than from the epidural.

There are some risks to the baby, as well, but how significant these are, is where a lot of the controversy arises concerning labor epidurals.

Pitfalls in Interpreting Data about Labor Epidurals

As always, it is best to evaluate data from outcome studies, analyses, meta-analyses and so on yourself. If you are not a scientist in the field of the study, you need to at least ask if the study is valid enough from which to draw conclusions. Because each person cannot possibly do this, peer review and standards are in place to help with this daunting task. Unfortunately, some people have chosen to try to draw conclusions that just aren't valid. Sometimes, this is done intentionally to promote a particular point of view. Sometimes, it is done out of scientific or medical ignorance (again, intentional or not) when the scientific process is not understood. There are many pitfalls to interpreting data from studies. Epidural-related topics are no exception. Here are some examples of reasons why drawing conclusions, even when they seem to be supported by data isn't always accurate.

Some data is older. Higher concentrations of more potent local anesthetics may have been in use during the time the older studies were done. Currently, very low concentration local anesthetics are used in most epidural preparations. Therefore, some older data (which opponents of epidurals love to quote) are no longer valid.

There is a "chicken or the egg" effect with epidural anesthesia. It is unclear when interpreting outcomes of women who get epidurals if there is a "cause and effect" relationship or just an association. An example would be the small-framed woman who requests an early epidural because of excessive pain. She ends up getting a c-section for 'cephalopelvic disproportion'. A study that evaluates the percentage of women getting a c-section after epidural would include her. However, it may be that she was destined for a c-section anyway because the baby won't fit through her birth canal. She had excess pain for the same reason and was, therefore, more likely to request the epidural. There are many, many of these variables that are hard to tease out or control for in a scientific study.

There are many other confounding variables, also.

  • Some obstetricians are more likely to move onto C-section than others who are more comfortable with 'watchful waiting'.
  • There are many possible combinations of drugs that can be used in the epidural solution. The addition of different medicines to the local anesthetic can change the effect of the epidural.
  • Combined spinal-epidurals may be counted as 'epidurals' in many cases and may have different effects.
  • Some studies compare epidurals to intravenous pain medication and some compare them to no intervention.
  • First-time mothers may have different risk factors than women who have previously given birth.
  • Older mothers are more likely to end up with C-section than younger mothers. This is one of many, many factors that are usually not controlled for, especially in older studies.

The list goes on and on and on and the above is a VERY small sampling of issues that complicate the picture and make it difficult to understand a particular study's conclusions. Unfortunately, these variables are hard for the professional to sort out. When the non-medical professional tries to interpret the data, it is even more difficult. This also makes it easier for the caregiver with an agenda to misrepresent the data (knowingly or not so) to push their beliefs on women in their care.


EPIDURAL CONTROVERSIES - SUMMARY

Controversy
True or False or ?
Explanation
Epidurals prolong labor
TRUE
Women who get epidurals spend longer in the second stage of labor. This has not been correlated with higher c-section rates or poor outcomes for the babies, however
Epidurals lead to c-sections
FALSE
Women who use epidurals for pain relief do not have higher c-section rates than mothers using other types of pain relief (intravenous, for example)
Epidurals make vacuum or forceps delivery more likely
TRUE
It is generally accepted that there may be a higher rate of instrument-assisted delivery in women with epidurals. Further studies need to be done with the lower concentration anesthetics currently in use. Also, there are still some unanswered questions about confounding factors.
Epidurals make it harder to breastfeed
UNCERTAIN, MAY BE TRUE
While this may be true in some circumstances, further studies are needed. Mothers who get epidurals may report more difficulty with breastfeeding. There may be an ingrown selection bias, as women who are opposed to epidurals may already be more committed to breastfeeding. Other variables may also be at play.
Epidurals interfere with my baby's breathing
FALSE
Babies born to moms who get epidurals don't fare any worse than other babies.
Epidural and Fever
see discussion below in text
 
While there is definitely some individual variability, these are the currently accepted scientific positions based on the best available peer-reviewed studies and meta-analyses. Personal opinions and anecdotal 'evidence' will certainly stray from the

Epidural and Prolongation of Labor

Most of the current data suggests that epidural analgesia does prolong the second stage of labor, by about 5 percent. This prolonged labor does not translate to an increase in cesarean section rates. In other words, women with epidurals spend 30 to 60 minutes longer in labor, but are more comfortable (by most studies) and do not have increased cesarean rates.


Epidurals and C-Section Rates

Women with epidurals do not have a higher C-section rate than women receiving intravenous pain medication. It's possible that in some situations or labors, the epidural does contribute to further interventions culminating in C-sections. But, the assertion made by anti-epidural groups that this is usually, or always the case is not scientifically valid.

A Medline search, with the terms "epidural cesarean section rate", gives 587 results since the year 2000 in English-language, (mostly) peer-reviewed journals, showing that despite current evidence, this continues to be an area of active surveillance.

Medline Search: Epidurals and C-Sections

A search of Medline for relevant articles shows that the relationship between epidurals and c-sections will continue to be investigated.
A search of Medline for relevant articles shows that the relationship between epidurals and c-sections will continue to be investigated. | Source

Epidurals and Breastfeeding

Women who receive pain relief during labor may initially (first day) have more trouble getting baby to latch on and breastfeed, especially in the first day after delivery. Some reports seem to indicate that overall success is affected. Many reports find no difference in long-term success in breastfeeding. Further, attempts at studying different preparations of medications has not shed any light on this topic so far (specifically, fentanyl, a commonly suspected narcotic medicine that is often added to epidurals, does not seem to change the stats). Institutions with lactation support seem (not clearly scientifically valid, by report) to have a much higher success rate for breastfeeding mothers, with or without epidural use.

The correlation between epidural and breastfeeding is met with some skepticism as to a cause and effect relationship. It is also possible that women who are more likely to request epidurals, also have other risk factors for difficulty with breast feeding. There are several confounding variables that may make a definitive answer hard to reach on this topic, although some groups like Lamaze have already made their conclusions.

Epidural Effect on Newborn

Infants born to mothers who had epidurals seem to have adequate and comparable oxygen levels and Apgar scores to non-epidural births. In the absence of other risk factors, epidural alone does not seem to adversely affect neonatal outcome (with the exception noted below).

Epidurals, Maternal Fever and Newborn Risk

As studies of the effects of labor epidurals have tried to separate and clarify any risk, it has been discovered that some women develop an elevated body temperature after receiving an epidural. Further, the higher the mom's body temperature during labor, the more problems her newborn may have after birth.

This is an undesired finding that is the subject of very active study. Researchers and clinicians, as well as patients, want to understand the factors that lead to fever in the laboring mother, and the adverse effects on the baby. Finding the cause is the key to prevention.

So far, using a representative study ("Intrapartum temperature elevation, epidural use, and adverse outcome in term infants; Greenwell, EA; Pediatrics: Feb 1, 2012; 129(2): e447-54) we know that around 19 percent of women will develop a body temperature of 100.4F or higher. This is much higher than the 3 percent of women without an epidural reaching the same temperature.

In women who had epidurals AND fever of greater than 101F, the risk to the baby for weakness, seizures and low Apgar scores were 2 to 6 times higher than for women without BOTH of these factors. Women who had epidurals, but maintained normal body temperature did not see an increased risk to the baby.

We don't understand why some women develop fevers and others don't. But, prevention of the temperature elevation seems to prevent problems with the babies.

Again, this is relatively new information and investigation is ongoing, but still in its early stages. But, women should be aware of this risk.

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Comments 10 comments

eauinsite profile image

eauinsite 4 years ago from Anchorage, Alaska

This is some pretty useful information here. I have had 4 children, and after reading/hearing all of the horror stories regarding this topic, I was too scared to have one. I still don't think I would've changed my mind, but at least you're honest, insightful, and professional when depicting what it can actually do, or not do. Very well written article and thanks for shedding some light on a semi-controversial topic.


joyfulmom profile image

joyfulmom 4 years ago from Calgary, Alberta

very informative hub! I find it sad that you've been attacked because of your profession. thank you for sharing some great info!


TahoeDoc profile image

TahoeDoc 4 years ago from Lake Tahoe, California Author

Epidurals are not for everyone, that's for sure. I would never, ever want someone to get one without being properly informed (as best as is possible when they are in labor) or against their wishes.

I only hope to give as accurate information as possible and hope that women are able to find the best info BEFORE having to make a quick decision, with the added stress of labor and pain.

I had epidurals for both of my deliveries, so at least for me, knowing what I know, the benefits outweighed the risks (I had a slowing of labor that actually sped up after the epidural, presumably because of muscle relaxation and alteration of stress hormones).

I applaud women who don't get epidurals because they don't want or need them and have decided that is the best decision for them. I also commend women who decide an epidural can help them and are willing to trust me to help care for them.

I hope that the judgmental divisiveness between those who are anti-epidural and those who are not can just stop. Everyone has the right to decide what is right for their situation.

Thanks for the nice comments :)


nikinoo profile image

nikinoo 4 years ago from Past Cloud Nine

This was a very good article. I am currently pregnant with my third pregnancy with my fourth and fifth child and for the previous 2 pregnancies i chose to have one. Like you the anesthesiologist was very informative. I truly wish there were more people like you out there in the healthcare profession.


TahoeDoc profile image

TahoeDoc 4 years ago from Lake Tahoe, California Author

Thank you nikinoo. It really comes down to making an informed choice. The hardest women to give epidurals to are the ones who didn't bother to research them or learn anything about them because they were SURE they would never ask for one...

Then they ask for one...

but are almost hostile or resentful about it. Not only are they in pain, aggravated and unable to really process what you are telling them, they are unlikely to remember much of what is said. Then they get mad later that they didn't know about X, Y or Z- which of course they did hear about, but were in no condition to remember.

The point is that a little research of good, reliable science-based, information can prepare each woman to make the decision that is right for her, whatever that might be.


Marcy Goodfleisch profile image

Marcy Goodfleisch 4 years ago from Planet Earth

I've always been confused about the difference between epidurals and spinals. Having had one of those (not sure which) during my first labor, I would hesitate to get it again after the headaches I had. Childbirth was not as bad as the pain afterward (and I'm comparing it to birth #2, where I had very little anesthetic other than for the incision).

Your hubs are so educational - thanks for sharing this information and your expertise! Many votes up!


pharmacist profile image

pharmacist 4 years ago from Whitinsville, MA

TahoeDoc,

An amazing and comprehensive review of an important - and as you mention - often controversial issue. You are much appreciated! Great to hear a "voice of reason" amidst the clamor of confusion that so often abounds the medical information market. A happy follower...


healthmom profile image

healthmom 3 years ago from Ohio

As a medical professional myself, I enjoyed reading your article. I didn't have an epidural with both my kids, but I researched the topic extensively and knew I had it as an option. I decided that if the pain was too intense, epidural would be my first choice, over IV pain meds. Thankfully, I had fairly routine births with both without back labor, etc.

Very informative hub! I also am saddened and frustrated when patients feel like the entire medical profession has made a pact to deceive them and force procedures. The majority of us studied medicine because we really wanted to help other people. I know there are bad apples, but it's that way in every profession.

Even though I didn't have an epidural, I am comforted knowing that option is there for me with baby #3 if I need it. And that it will be available for my daughter when she goes through labor, if she decides to have kids when she's older.


TahoeDoc profile image

TahoeDoc 3 years ago from Lake Tahoe, California Author

What a great comment- thank you! I get so sad when I think about how the public perceives medical care providers. I would never force anyone to do anything they didn't want- and quite honestly, if someone doesn't want an epidural, am often quite content NOT to drive in at 3am for some dollars when I worked all day and will work all the next day. I just want to make sure that options are available AND if I can help and someone wants my help, then I will enthusiastically provide it. That's all. No conspiracy, no deception, no 'selling' of procedures. I'm so glad I'm not the only one who is disheartened by this. I have cut back the time I spend in clinical medicine and frustrations like this are a big part of this. Sigh.

I really did go into medicine to help people and I chose anesthesia to alleviate pain, anxiety and suffering during vulnerable, scary times in patients' lives. Anyway, that's one reason I write. I just want to provide information and I am very, very cautious to be able to back up what I say with research. It's tedious, but there is so much crap info on the internet that I hope to become a source of reliable, verifiable info.

I hope my articles help people make INFORMED decisions about what is best for them, in their situation just like you did. You knew what your options were and could make an educated decision. Even though you didn't get the epidural, you were aware of the options/limitations/risks/benefits and potential issues.

Thanks again for reading and taking the time to comment!


poweranni profile image

poweranni 2 years ago from Los Angeles, CA

excellent article!

As an absolute non-physician, I will add my perspective.

I think that people really don't fully know what their "beef" is with medical professionals like you.

I think that their issues have little or nothing to do with your professionalism or your knowledge, etc.

There are a couple of cultural trends going on.

1. (From a layman's perspective) the bloated cost of healthcare. Physicians obviously want to play it ultra-safe because they don't want to kill anybody or anybody's baby/fetus etc. Therefore, even if there is a shade of doubt, they recommend more screening and most of these bloodtests and ultrasounds cost more than $3.50. And the insurance obviously gets the bills but a good percent of that cost is past onto the subscriber.

I am pregnant and after getting some of these bills for extensive lists of procedures and tests, for stuff that I have a 1 in 18,000 chance for, I can see their point of view but they are what you call "barking up the wrong tree" to rant at people like you.

2. There is an anti-authority "ethic" (and I am not so sure it is a good one). Basically almost every profession these days faces a wall of vocal critics who really don't know nearly as much as they think they do.

I'll give you an example. Pet food. Some people feel like they should only feed a dog and cat raw meat and byproducts. So instead of buying friskies (evil corporation) go to the butcher shop and get some raw offal (or go to the incinerator and pick up some medical waste if you will) and feed it to Fefee.

Or they feel that going to Safeway or Walmart and buying Purina (who have EXTENSIVE funds for R & D and have been doing this for over 70 years ... is unethical and wrong and unhealthy for their pets. Instead they need to buy a premium kibble, from a start-up that costs more per day than what my neighbors pay to feed their kids.

But the people who bicker about this stuff are generally not veterinarians. They are people like me, with degrees in liberal arts or social science, or no degree whatsoever.

When my cat got a series of urinary track infections, we followed the veterinarian's advice like Gospel.

Why?

Because I DID NOT TAKE THE DAMN COURSE IN BIOCHEMISTRY that he had to ACE in order to get into veterinarian school.

But funny how people who excelled in those fields are generally not the critics of things like commercial dog kibble and epidurals.

I did not take the courses, and I don't spend my nights and evenings on ebsco host researching these topics. I have the skills, sure. I just don't have the interest and the discipline for it.

Therefore I am exceedingly grateful that a person like you writes an article like this one, "spoonfeeding" the public with the most relevant "soundbites" about this topic.

3. There is also the issue of people simply being uninformed. That is not just among patients. The customer service representative at the local Walmart has similar complaints. If you are standing on the "giving" end of a service, you see a very different side of it, then if you are on the "receiving end."

----

Thank you for sharing this information and you sound like a wonderful professional and I wish you were the one coaching me through labor. Sadly you are far away, as I am in Los Angeles.

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