Benefits and harms of epidurals

2023 Author: Anita Thornton | [email protected]. Last modified: 2023-11-27 18:44

It is good to state the following fact from the outset: the epidural is today and without a doubt the most powerful pain management tool in childbirth or in surgery with spinal anesthesia.

Useful or useless?

It is one tool among others, which must be presented as such to couples who are going to give birth: as with any medical device, it has its advantages and disadvantages, it may prove to be particularly appropriate in certain situations, but harmful in others. To a woman alone, without support, unprepared for the intensity and the meaning of what she is about to experience, an epidural will surely be useful. During an endless dilation (we agree that below twenty hours of active labor for a first baby, we remain in normality) and exhausting, slowed down by physical, nervous or psychological tensions, during an initiation with synthetic oxytocin, when the pain becomes distress and suffering, the epidural is recommended and can promote the opening of a tense cervix.

But in 85% of cases (proportion of so-called physiological, “normal” deliveries), with the continuous support of thespouse, dedicated nurses, birth companion or midwife, epidurals are often unnecessary and sometimes harmful to the smooth running of labor and well-being in the medium and long term of the mother and the baby.

Assess the risks

The question is therefore not to condemn the use of epidurals in absolute terms or to deny the considerable medical progress it represents, but to expose all the possible repercussions. It is important to return to the notion of probability, which is often misunderstood: to say that an epidural increases the probability of occurrence of complications (prolongation of labor¹, instrumental birth^{2, use of other medicinal substances and devices, difficult breastfeeding) is no guarantee to the woman who requests it that her delivery will end up being highly medicalised.}

In a large number of cases, these complications are non-existent or perceived as being "a lesser evil" (difficulties in starting breastfeeding cannot deter medical staff from advising an epidural) so that the epidural remains a tool of choice in hospital deliveries. But in a significant proportion of cases, we are witnessing a cascade of interventions ending too often and logically with one or more suction cups or forceps or with a caesarean section. The link between epidural and caesarean section is controversial, it would in any case be increased for a first baby3. The objection “I took the epidural andeverything went well” does not in any way invalidate my demonstration.

What are the possible complications?

By preparing the couples I accompany, I notice that their greatest awareness during the follow-up concerns the potential risks of the epidural, those which are not talked about enough.

Anesthesia

When we talk about risks, we think of those that the anesthetist tells us about, well known, on which I will not dwell: as with any anesthesia, there is a certain margin of error and possible adverse reactions. Each body is different, and despite all his skill, the anesthetist cannot guarantee that the relief will be sufficient or uniform. We sometimes have to prick two or three times to reach the desired epidural space. It is difficult to know in advance your threshold of reactivity: some women are immediately frozen with a mini dose, others will still be in pain after several boluses (doses) of medicine.

Synthetic Oxytocin

You are told beforehand, but most often afterwards, that you will also have a solute and most likely syntocinon (synthetic oxytocin), but also a urinary catheter to evacuate all this liquid that your sleeping bladder will tend to keep, hindering the passage of your baby. Your baby's heart will need to be monitored regularly, in 20 to 30 minute increments.

Possible consequences

That's what you often learn on the job. The reasons why theepidural is accompanied by a solute, synto, monitor and a catheter in the urethra, they are rarely explained to you. Let's start from these corollaries to discuss the possible consequences of the epidural:

Pressure drop

If you are given solute, one of the effects of the epidural is to lower your blood pressure⁴. This effect is counteracted by a continuous injection of liquid, up to two, three, four liters or more: there is a good chance that your legs will be swollen and that you will urinate abundantly in the hours or days following your delivery.. Solute gets to the baby: it is only water with glucose, which will not harm him, but will artificially inflate his weight. It is possible that when you go home, the pediatrician judges that your child's weight loss exceeds the 10% tolerated^{5, and that he lengthens your stay at the hospital.}

Analgesia touches baby

If we monitor your baby's heart as soon as the product is injected, it's a good thing that, contrary to what you may be told, it reaches your child. No analgesia spares your baby⁶. Your child may be more sleepy⁷ at birth, and in the most severe cases, have respiratory distress⁸ and that her breastfeeding reflexes (digging, crawling, grasping, sucking, etc.) are diminished^{9. Studies have shown that a baby's immature liver can take up to 6 weeks to mature.get rid of the last drug molecules received by his mother during birth. When you know the rotation and bending movements that your baby will have to make to get out of this narrow channel that is your pelvis and your vagina, it is a good idea to wonder about the impact of an analgesic liquid on the vivacity of your child, and therefore on his ability to fulfill his role as a baby: to be born.}

Significant decrease in mobility

If you have a catheter placed in your bladder, it is assumed that you will not be able to get up to empty it yourself. “Walking epidural” (a combination of local anesthetics and morphine-like analgesics, which lessen the paralyzing effect of the lower limbs) is rarely available, many side effects are the same10and no one can predict your body's reaction. With a catheter in the back (the small tube that circulates the liquid in your column remains permanently, until after birth) and another in the bladder, a venous access in which flows a solute, synto, perhaps Benadryl if the epidural, as often, makes you itchy, and the fetal monitor belt, you will not be very nimble.

However, the question of the mobility of the mother, and by extension of her pelvis, during childbirth, is major: we are the only species whose baby presents a head so large in proportion to the body, a head whose diameter is very close to that of the pelvis of hismother, but which is perpendicular to the pelvic oval: the baby must turn his head to the side then put it back in the axis and finally flex it to correspond to the three non-stackable straits which constitute the birth canal. It will therefore be necessary to have close cooperation between the two actors of the birth, to optimize the opening of the pelvis and the passage of the baby at each stage. The position on the back is the worst possible way to lower a baby: this is why the scientific world agrees that the main risk associated with an epidural is that of an instrumental birth (with forceps or a suction cup)^11.

The intensity of the contractions

If you are injected with syntocinon (or pitocin, it's the same thing) in your veins, it is to strengthen your contractions. If your contractions need to be strengthened… they have diminished in intensity. Two reasons for that:

• the first is mechanical. Your cervix needs contractions to dilate, but also the optimal pressure from your baby's head (or buttocks). Lying on her back or on her side, your baby no longer benefits from gravity, and her pressure on the cervix is not optimal. I even saw a small baby move into a transverse position after two hours on his back, and another move from anterior to posterior position after a night in bed. This is why giving birth on an epidural can take longer.
• The second is hormonal. To give birth, you need a hormonethat all women naturally secrete, if the surrounding conditions governing its production are satisfactory¹², oxytocin. And whatever you are told, synthetic oxytocin is NOT your natural hormone. Yours, it has the gift of boosting the production of endorphins, which help you to manage your pain, to rest between two contractions, rest which allows, even in thirty seconds, to relax your cervix. Synto or pitocin causes artificial contractions, reflexes, of your uterus, much more difficult for you and your baby to bear: this is another reason why with synto, you are under continuous monitoring. It has been proven that with the use of pitocin, there was more fluid tinged with meconium when the waters broke, therefore more fetal distress¹³. There have also been more postpartum hemorrhages¹⁴: this is why the nurse carefully feels your belly during synto contractions, to check that your uterus is not tetany 15^{, which could be very dangerous for your baby. Finally, after hours of artificial contractions, the uterus is more tired, and less able to contract to expel the placenta, which is postulated by studies pointing to a correlation between the use of synthetic oxytocin and the incidence of 'postpartum hemorrhage.}

Synthetic hormones to replace natural hormones

But let's get back to the hormonal cause of the decrease in contractions "spontaneous" contractions under epidural: your brain will produce the hormones necessary for childbirth (prostaglandins, oxytocin, endorphins, then adrenaline at the time of the push) when the baby and the placenta emit specific hormonal signals, then when the sensation of pain reaches the brain via the sensory-motor nerves, housed in the spine. This is how the epidural works: you deceive the brain somewhere by cutting off the road to pain, which no longer reaches you. If the pain no longer reaches the brain, which controls the endocrine glands, these will stop producing the hormones for childbirth¹⁶. And we're going to have to restart labor by injecting synthetic oxytocin into your veins, which this time will not be accompanied by endorphins¹⁷. Hence the immense challenge of having a induced labor with synto or pitocin: the pain is not gradual, it is sudden and unbearable, and nothing helps you to endure: neither mobility nor your endorphins. We now understand why epidural and pitocin go so well together.

It has also been suggested that the local analgesics used in an epidural have an effect on the uterine muscle itself18. It is common sense to wonder about the extent of anesthesia that freezes you from navel to toes while sparing your uterus…

The use of childbirth tools

A few details on what requires the use of a suction cup,forceps, or a caesarean section to extract a baby unable to come out. As we have seen, the baby is less lively, he undergoes artificial contractions which may be excessive compared to what his heart can support, and he evolves in a pelvis immobilized by the position lying on his back. This video illustrates very well what is called the nutation of the sacrum and the retropulsion of the coccyx, pushed backwards by the baby's skull, in order to let it out. With your buttocks pressed down on a bed, your sacrum and tailbone won't go anywhere, and your baby will have to overcome the promontory they represent to get to you.

Add to that the numbness of the mother who does not feel her contractions or hardly feels them and who cannot hold her legs herself (and even less on her legs, in a position other than lying down) and the weakness hormones naturally associated with the end of labour

19^{, we have here the perfect cocktail for a long, directed push, which often results in the use of instruments and sometimes in an episiotomy, the first culprit for major tears of the 3}e ^{and 4}e ^degree.

Epidural: more than a question of philosophy

Before giving birth myself and then doing this job, I thought that the use of epidurals was an ideological question. I continue to think that experiencing birth without an epidural gives us access to a certain experience of motherhood, a source of power and pride. But after conversations with doctors andmidwives, many readings including those of texts from the WHO20 or from the Cochrane Library, and numerous experiences of support without and with epidurals in the hospital, the question is first, in my opinion, that of managing the increased risks to which this tool exposes, and of its appropriate use, restricted to the small number of cases for which it is really required. We must not forget that when a woman asks for an epidural, it is above all a lack of support that she complains about.

Finally, I must emphasize that before any dogmatism, you have to be realistic and give yourself the means for your project: the hospital context does not encourage women to try to live by themselves what their body knows how to do it perfectly, provided that he is given the time, in the very large majority of cases. The pain of childbirth is immeasurable, and no one can be blamed for wanting to suppress it. Without careful (and realistic, again) preparation and, above all, supportive support, the challenge of giving birth naturally in the hospital can be difficult.

To go further

• sarahbuckley.com/epidurals-risks-and-concerns-for-mother-and-baby
• The hidden risks of epidurals, Dr Sarah Buckley, in French
• Classifications of practices according to the WHO
• summaries.cochrane.org/CD000331/PREG_epidurals-for-pain-relief-in-labour
• summaries.cochrane.org/CD004457/PREG_discontinuation-of-epidural-analgesia-late-in-labour-for-reducing-the-adverse-delivery-outcomes-associated-with-epidural-analgesia