Childbirth That’s Not So Labor-Intensive
Like many mothers-to-be, Kristine Lain really wanted a natural, medication-free childbirth. And like many women who have endured labor, she now wonders what ever possessed her.
“I definitely wanted to try for the natural experience,” said Lain, the mother of two with another one on the way. “I thought, somehow, that the experience would be more real, that with an epidural I wouldn’t have the same emotional connection to my baby.”
Lain, 32, now laughs at her earlier notions. After all, as a staff obstetrician at Magee Women’s Hospital in Pittsburgh, she should have known what to expect. Instead, she learned firsthand what more women are discovering: There is such a thing as too much reality.
According to a report presented in the fall at the annual meeting of the American Society of Anesthesiologists, the number of women requesting epidurals for vaginal deliveries at large hospitals has tripled in 15 years. Researchers from the University of Colorado School of Medicine in Denver tracked anesthesia use in 750 hospitals nationwide and found that the number of epidurals used during labor rose from 22% in 1981 to 66% in 1997.
In some Southern California hospitals, those numbers are even higher. At UCLA Medical Center, for example, the rate of epidurals used for vaginal deliveries rose from 35% in 1985, to 60% in 1990 and 85% in 1999, according to Dr. Anita Backus, the medical center’s director of obstetric anesthesia.
Dr. Joy Hawkins, author of the national study and director of obstetric anesthesiology at the University of Colorado medical school, attributes the increase to several factors: Epidural techniques have improved. More anesthesiologists are available at hospitals of all sizes. Obstetricians are more actively managing labor. And women are more informed about their options.
Further, 50% of the women in the nationwide study opted for some form of narcotic pain relief, usually an intravenous medication like Stadol or Nubain, instead of or in addition to the epidural.
Many women start with the narcotic to take the edge off the pain. When that isn’t enough, they ask for the epidural, a regional anesthetic injected into the epidural space below the spine that eliminates sensation from the waist down. “Only about 10% of women have nothing,” Hawkins said.
The increase in epidurals comes after a focus on natural childbirth in the 1970s and ‘80s.
“Natural childbirth lost favor because it didn’t work for many women,” said Ingrid Rodi, an ob-gyn and medical director of in-vitro fertilization at Century City Hospital. “Women were told, ‘If you just breathe rhythmically, play soft music and get the lights right, the rest will take care of itself.”
That emphasis, in turn, was a reaction to the heavy-handed approach doctors took during the middle of the century, said Dr. Alan DeCherney, chairman of obstetrics for UCLA School of Medicine. From the ‘40s to the mid-’60s, women were usually unconscious during their labor and delivery. When the woman woke up, she would have a baby but remember nothing of the event.
Today, women have become more comfortable with medicine again, DeCherney said, and they’re making choices that reflect their priorities.
Cyndi Hung of Westchester, who delivered her third baby in February, is among the women who gathered information about various forms of childbirth and then opted for pain relief.
“I’m not a martyr,” Hung said. “There’s not a prize for doing this naturally.”
All of Hung’s children were born vaginally, with epidurals. Before her first child was born in 1992, she attended childbirth classes at Stanford Hospital at Stanford University, where she delivered. “They presented all the options and didn’t push any one. I wanted to know my choices, so I would be prepared to make up my mind when the time came. I was open to whatever worked for me.”
As her labor pains grew more intense, she took a narcotic to reduce the pain, but that did nothing for her. At the same time she got pitocin to encourage contractions. The pain worsened and she opted for the epidural.
“I went from being really tense and hurting to relaxed and smiling. I could concentrate much better,” she said. The feelings were the same during the birth of her second child in 1995 in Santa Monica. But in February, when in labor with her third child, the epidural didn’t take. (Because of anatomical differences, sometimes the medication simply doesn’t hit the right nerves.) “It felt just like natural childbirth, except that I paid for an epidural.”
Still, she would have the epidural again, she said, “even given the what-ifs, because it’s so much more pleasant [when it works].”
A Tempting Option
Jill Huppert, an ob-gyn who delivered without anesthesia on a Navajo Indian reservation 10 years ago, said, “When someone waves an epidural at you while you’re writhing in the pain of transition and says, ‘I can take your pain away,’ it’s like the last temptation of Christ. Who can resist? None of us is Christ.” (To deliver a baby vaginally, a woman’s cervix needs to widen to 10 centimeters. The point at which a woman’s cervix widens from 7 to 8 centimeters is called “transition” and is considered the most painful part of labor.)
Huppert, now an assistant professor of obstetrics at the University of Cincinnati, said previous back surgery more than stoicism prevented her from having an epidural. To administer an epidural, doctors insert a fine tube into the epidural space in the lower back. Scar tissue can interfere.
By the time Huppert delivered her baby, she was wiped out. “There was none of that early mother-child bonding you hear about. When I was done, I was so exhausted, I said to my husband, ‘You hold it.’ ”
Still, Huppert’s a big fan of natural childbirth: “I’ve seen it work and it’s so beautiful.”
Natural childbirth was Lain’s goal. Even though she knew that 80% to 90% of the women in her practice received some kind of pain relief during labor, she hoped she’d be different. “Something inside almost every woman says we’re supposed to be able to do this without help. It’s natural,” Lain said.
She now knows the difference an epidural can make. Five years ago, when having her first child, she withstood 12 hours of induced labor (her hypertension led to a scheduled delivery) before seeking pain relief. “I fell asleep, then woke up and needed to push,” she said. “I didn’t feel that I’d caved in at all.”
Women who once resisted epidurals now welcome them because they’ve improved over the years. Recent studies have laid to rest concerns that epidurals increase the chance of a forceps delivery or a C-section. Today’s epidurals not only can be controlled so a woman can push, but also can allow a woman to walk during labor.
Some Complications
But epidurals still carry risks. In about 10% of cases, the woman’s blood pressure drops, but doctors can easily manage that, Hawkins said. And finer needles have reduced the incidence of the debilitating epidural headache to about one in 200 cases.
Rarer complications, such as difficulty breathing if the epidural travels up rather than down the body, or nerve injury, occur in about one in half a million instances, she said. But for the great majority of women, they offer safe and complete relief, Hawkins said.
In her study, Hawkins also noted that more anesthesiologists were available, making epidurals more available. In 1981, obstetricians provided 26% of the epidurals used for vaginal delivery. In 1997, obstetricians provided “virtually none.”
As for active labor management’s role in the rise of epidurals, not all childbirth experts are pleased. The term refers to the common practice of physicians actively moving slow labors along through medications, such as oxytocin (commonly called pitocin), which promotes labor.
Some say the motives behind active management are economic, that it simply moves patients through the hospital faster, especially those who come to the hospital too early in their labor.
Others say that active management benefits patients and babies. In a large-scale study out of the National Maternity Hospital in Dublin, Ireland, researchers found that prolonged labor can increase the risk of C-sections, sometimes because women stop dilating. Also, if a woman’s water has broken and her labor is languishing, mother and baby have a greater risk of infection.
Most experts believe that oxytocin makes for a harder labor. “If you’re getting pitocin,” said Rodi, “you’d better have pain relief on board.”
Lorri Walker, a certified nurse midwife and director of the South Coast Midwifery in Lake Forest, believes that less medical management would equal more natural deliveries.
“I’d rather see labors progress on a more natural curve. As a woman loses the feeling of control, her pain snowballs and she can’t handle it. She starts wondering what all those [childbirth educators] were talking about. The breathing and relaxation techniques don’t work, and she feels betrayed,” Walker said. “Women really want natural birth, but, because active management is the standard of care, the [coping] methods they’ve learned are useless.”
Walker, a mother of three, ages 20, 19 and 17, gave birth to all of her children in the hospital without medication. “I’m proud of that accomplishment, about being a woman and being strong. It’s such a wonderful empowering experience,” she said. “I thought at the height of my pain that it was unbearable and I wouldn’t be able to go on, but I had supportive people telling me this will soon be over. And then it was pure elation.”
Regardless of their views on intervention, no woman in the baby delivery business feels quite the same about childbirth after she’s gone through it.
“Before you do it yourself, you think these women are just losing control,” Huppert said. “Then you too experience that weird stage where you go from human to animal, and you’re grunting instinctively, and you understand their experience.”
Lain too has changed her counsel since giving birth: “I’m much more realistic that every woman’s pain threshold is different. I try to talk to patients about options and let them know that their preconceived notions may be very different from what happens, and not to think of themselves as a failure if things don’t go as planned.”
