Taking the Labor Out of Labor
It wasn’t all that long ago that childbirth was painful.
Extremely painful.
But in a phenomenon rich with social, political and economic overtones, childbirth in America has shifted dramatically to the quest for comfort.
So strong is the trend toward the use of anesthesia--particularly the epidural--that even well-reasoned questions regarding the appropriateness and downside to pain relief are not dampening the enthusiasm.
Which leads to the question: Given continuing innovations in anesthesia, will pain during childbirth become only a memory preserved in family folklore?
“In the last 15 years, we’ve gone from medication in labor being tantamount to hurting your baby to now saying, ‘Why would you not want pain relief in labor?’ ” says Dr. Michael Nageotte, an obstetrician at Long Beach Memorial Medical Center.
“What is so interesting to me about the epidural issue is that it’s not primarily a medical issue. Labor pain is viewed by some people as normal and, therefore, it doesn’t have to be removed. But if you’re in it, it’s extremely painful.”
Epidural is a type of anesthesia in which a needle is placed into the space outside the spinal cord and a liquid anesthetic is administered to numb the pain-sensing and motor nerves. In recent years, the method has taken the obstetrics world by storm. According to the American Society of Anesthesiologists, 16% of women who used anesthesia during childbirth received an epidural in 1982. A decade later, that number had soared to 33%.
And now, about 1 million of the 4 million U.S. women who give birth every year receive an epidural to cope with pain. And innovations promise to make the technique an even more attractive option.
Despite the fervor for epidurals, however, unresolved issues persist on several fronts. Among them: a lingering debate on whether women who have epidurals have a higher rate of caesarean section, and a link between epidural use and maternal fever that may lead to unnecessary medical treatment of newborns.
“What would be great is if we could eventually tailor the epidural to minimize the risks,” Nageotte says.
Doctors, including Nageotte, are now testing a more sophisticated epidural--called a walking or combination epidural--that allows women to move around while anesthetized. A drawback of the traditional epidural is that it prevents sensation and movement in the legs. Many women using epidurals say they are even unable to move their muscles to push the baby from the birth canal. And studies show that the second stage of labor--when the cervix is fully dilated and pushing can begin--is lengthened with an epidural. There is even some question as to whether a stalled labor ultimately increases the odds of a C-section.
It’s not known, however, if being able to walk around will hasten labor and reduce risks.
“That’s the question,” Nageotte says. “There is a firm belief that women who can walk around can hasten the onset of labor and shorten the duration of labor. But that’s not in the literature. That remains to be seen.”
The combination epidural works similarly to the traditional epidural except that a needle is placed directly into the spinal fluid.
“But we can administer a much lower concentration of anesthesia, about half or even less than what we would normally use,” Nageotte says. “The end result is that the patient doesn’t lose the use of her lower extremities. It preserves motor function.”
The combination epidural provides pain relief for a much shorter window--about two hours--than a traditional epidural, he adds. The anesthesiologist’s goal is to administer the drug so that it will be wearing off when it’s time for the woman to push.
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While the combination epidural may prove to offer some advantages and may eventually help reduce C-section rates, there is less optimism that the link between epidurals and maternal fever can be resolved.
According to a recent study published in the journal Pediatrics, women who have epidurals have a much higher rate of fever during labor and delivery. The study found fever of 100.4 degrees or greater in 14.5% of the women who used epidurals compared to only 1% among the other women.
Fever in a woman in labor is a concern because it can signal the presence of an infection in the baby. Typically, if the mother has a fever, her newborn immediately undergoes blood tests to check for infection and may even be started on antibiotics as a precautionary measure, says Dr. Ellice Lieberman, an obstetrician at Boston’s Brigham and Women’s Hospital and the study’s lead author.
“The exact reason why women get fever is not entirely clear, but it seems to have to do with her ability to regulate her body temperature and not because there is an infection. The problem is that it’s not possible for the doctor to know if the fever was caused by the epidural or an infection. And sepsis [a bloodstream infection] in the baby is not something you want to miss,” she says.
In both groups of women, the rate of infection in the babies was actually very low, 0.3% in the epidural group and 0.2% in the other group.
“It should be stressed that the study in Pediatrics does not conclude that epidural anesthesia causes fever in the mother or infection in the baby,” notes Dr. Phillip O. Bridenbaugh, president of the American Society of Anesthesiologists. “It would be a great disservice to all pregnant women if they are unnecessarily frightened or misled about the safety of epidural blocks.”
But sending the baby for tests is painful for the newborn and upsetting for the parents, Lieberman says. Moreover, babies who are put on antibiotics sometimes have to remain in the hospital after the mother is released. There is also no information on whether unnecessary antibiotics are harmful to a newborn.
“This is not something we can get around today,” Lieberman says of the dilemma. “An epidural provides the best pain relief for labor that we have. You have to weigh that against possible fever and that epidurals may increase the rate of C-sections. I think it’s important for women to be informed about this. Each woman can then go over the pros and cons.”
