by Sarah Buckley, Brisbane, Australia
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
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 round 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
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
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
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.
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
3 World Health Organisation. Care in Normal birth: A Practical Guide..P 16. WHO
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]
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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
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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;
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
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21 see 13
23 Rawal N, Arner S et al Ventilatory effects of extradural diamorphine.Br J
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
25Fernando R, Bonello E et al. Placental and maternal plasma concentrations of
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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
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
32Goodfellow CF, Hull MGR, Swaab DF et al. Oxytocin deficiency at delivery with
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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;
39 Rosenblatt DB, Belsey EM, Lieberman BA et al. The influence of maternal
analgesia on neonatal behaviour II epidural bupivicaine. Br J Obstet Gynecol
40 Seposki C, Lester B, Ostenheimer GW, Brazelton, TB. The effects
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41 Murray AD, Dolby RM, Nation RL, Thomas DB.Effects of epidural
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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)
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