The Epidural: Less Satisfying and More Painful Birth?

Pregnancy and birth are filled with many unpredictable features, whether this be your first go at the rodeo or 5^th.

Pain experienced during labor is also unpredictable. Pain may be manageable without medication, or it may become severe and exhausting.

If you find yourself calling the United States your home, then you are among the majority if you opt for epidural pain relief during labor.

Ladies in the U.S. have fewer options for labor pain management than our counterparts in other industrialized nations (such as the UK and Canada). It is uncertain if the excessive use of epidural analgesia is a true preference in the US or if it is simply chosen because of the lack of other presented options.[*]

Interesting, none-the-less….

What is certain is that epidural use is nearly always an elective procedure. Although it can be a useful tool in supporting a laboring mother, the use of epidural medication expands the chance for complications, this does not occur in drastic numbers. Each family has their own comfort level with side effects and risk – what one family may consider safe, another may become uncomfortable. (you can learn more about risks associated with epidural use here and here) 

Everyday, devoted and loving soon-to-be mothers opt for epidural anesthesia pain relief during the birth of their babies.

I was among them, choosing an epidural with my first daughter because I thought it would help with pain and allow me to have a more enjoyable experience. In actuality, I experienced agonizing break-through pain and a cascade of interventions that I wasn’t anticipating (urinary catheterization, artificial rupture of membranes, internal fetal monitoring, use of synthetic oxytocin). 

Was my disillusionment with epidural anesthesia in the minority? 

Higher Pain Recall Among Those Opting for Epidural Analgesia

A remarkable finding from a longitudinal study (2009 BJOG) regarding women’s memory of labor pain found that mothers who opted for epidural analgesia reported higher pain scores at all time points versus those who went without.[*]

Another study (2006 JPOG) substantiates the above findings and also goes to on to provide data that women who received epidural analgesia not only had higher recollection of intense pain at two months and one year but also had greater difficulty forgetting pain 10 months later.[*]

If a mother chooses an epidural in most part to experience a labor that is less painful then one without anesthesia the data above can be sobering.

Research also suggests that pain experienced during labor is not entirely a negative experience, with more then 1 out of 4 women (28%) assessing pain as more of a positive than a negative – suggesting that coping with pain is a rewarding experience for some women.[*]

Lower Satisfaction Among Those Opting for Epidural Analgesia

Although women and care providers may assume that effective pharmaceutical pain relief during labor will ensure a more positive birth experience, there is mounting evidence that the opposite is true.

Several studies have shown that women who use no labor medication are the most satisfied with their labor and birth (times being assessed at time of birth, six weeks and one year after birth).[*][*][*][*][*][*]

Also worth noting, women who cope with labor using non-medical alternatives such as water birth, massage, positioning, focusing and breathing done with the support of another person report more satisfied than with standard pain relief given during childbirth.[*]

Natural techniques utilize a woman’s own strengths and places her in control of her own body. They also have been assessed to improve obstetric outcomes compared to pharmaceutical relief.[*][*] 

Interestingly, the influence of pain relief on satisfaction is not as powerful as the attitudes and behaviors of the mother and caregivers involved. Consider a 2002 study published in the American Journal of Obstetrics & Gynecology which concludes four factors that appear to override pain experienced in labor:[*][*]

1. Personal expectations

2. Amount of support from caregiver

3. Quality of caregiver-patient relationship

4. Mother’s involvement in decision making

This reaffirms the main key to satisfaction and managing labor pain effectively, is to ready yourself in advance – arranging continuous support, accurately understanding pain control options (and the interventions involved) and having an active role in the decision making process.[*][*]

****

As much as some might like to discount natural childbirth as a progressive trend among a small number of women, research affirms that women who opt for epidural anesthesia experience more pain, have a more difficult time forgetting the pain, and experience less satisfaction overall.  

Women do not decline an epidural simply to “win a medal” – instead information on different types of pain relief are assessed and balanced against other goals such as walking, pushing effectively, or minimizing maternal/neonatal side effects and/or risks.

How much of an effect an epidural medication can have on a newborn or mother is not easily predetermined and can vary based on dosage/mix of pharmaceutical drug combination, the length of labor, and each individual.[*]

Opting for an epidural anesthesia is one method (among many) that can aid in relief of pain and discomfort during the labor process. This type of pain relief requires a mother to give some control to the hospital staff. It does involve risk and additional intervention.

The decision, rightfully, rests for each woman to make. In due course, researching the procedure and talking others who have may be able to offer different perspectives could help a mother decide on what is right for them.

As the data suggests, most women who choose unmedicated birth (and prepare for it) find the pain intense but manageable and they are happier with their experience afterwards.

Ultimately, what can be said, each woman should use the insight into herself to be the best guideposts in directing her toward a positive decision regarding pain relief during labor.

"You gain strength, courage and confidence by every experience

 in which you really stop and look fear in the face."

- Eleanor Roosevelt

Witness to Normal Birth

It was about the best thing I ever experienced.

The minute she came out, I was born again. It was like we’d just been born together.



paper dolls photography



If you are privileged enough to have witnessed a woman giving birth naturally in a place she has chosen, what will you have seen?

You will first be in awe of her strength.

 

And you will think – for how could you not – what a phenomenal creature a woman is. But you will only have seen this astonishing sight if you have understood that if you disturb her in her work, she will be thrown off course. One must sit quietly and patiently, almost invisible, breathing with her, not disturbing her internal rhythm. And you will see that the pain of her labor seldom overwhelms her.

A deep significance to the mother, the momentous quality of pain, as she is surrounded by the deep sense of inwardness, forced to recognize her independence, her loneliness, selfhood, becoming conscious of her own existence. Paradoxically, this actual self-consciousness exposes a woman to her wholeness, her strengths and her endurance.

Nature would not have organized labor to be intolerable. It is the limits of our human understanding that wish to control all that is surveyed, that has conquered women by making them labor in the most tortuous environment constructed.

Let us bring them into harsh rooms with bright lights. Let us make them lie on their backs on hard narrow beds. Let us tether them to machines so they cannot move. Let us make them stay silent. Let us restriction their eating and drinking. Let us expose their most private parts and threaten them with cold steel. Let us make them push their babies upwards, against the pull of gravity. Let us monitor and measure and chart every move they make. Let us swab, wipe, prod, poke, irate, confuse and frighten them as much as we can.

In these conditions, labor swiftly becomes unbearable and pain relief becomes a woman’s only hope. Get me an epidural, cut it out of me, anything, make it stop. Please help me!

This is not the natural cry of a woman in labor bringing a child into the world, although if you have only ever witnessed labor and birth in a medicalized setting you might be inclined to think so. Her only hope for salvation lies in the anesthetist who numbs the pain or the obstetrician to remove it.

And a woman spoke, saying, Tell us of Pain.

And he said: Your pain is the breaking of the

shell that encloses your understanding.

Even as the stone of the fruit must break, that

it’s heart may stand in the sun

so must you know pain.

- Gibran

Altered passage and excerpts can be found in:

Normal Childbirth: Evidence and Debate. Chapter: The Role of Pain in Normal Birth and the Empowerment of Women (Nicky Leap and Tricia Anderson). Pages 25-39. 2004. http://readinglists.lib.monash.edu/items/5BB0FE73-9C52-D121-1760-8D2D7F4AACC9.html

Surigical Birth: Recent Review Illustrates Risks of C-Section

Whether you are pregnant, have been pregnant in the past, have a friend that is pregnant, or you are of child bearing age – you might wonder if you will have a cesarean section in your future. Heck, the odds right now are pretty good that you very well might. Approximately 1 in 3 women have a c-section – the most common operating room surgery performed in the US.

You may even wonder if a c-section is safer or easier then having a baby the old fashion way.

A report published (DEC 2012) analyzes the available published research to compare health outcomes between cesarean delivery and planned vaginal birth. This report was developed to support the effort of the National Priorities Partnership (NPP) which is a group of 52 major national organizations with a shared vision to achieve better health and their goal of reducing c-sections in low-risk mothers in half - to 15%.  

This is what the assessment found:

Key: (of every 10,000 women or babies)

Moderate = 10 to 99

Large = 100 to 999

Very Large = 1,000 to 10,000

The physical effects in women following a cesarean deliver

Cardiac arrest: Limited evidence suggests that a MODERATE excess number of healthy women may experience cardiac arrest in association with cesarean delivery compared with similar women planning vaginal birth.

Urgent hysterectomy: A SMALL to MODERATE excess number of women having initial cesarean delivery undergo unplanned hysterectomy compared with women having vaginal birth.

Thromboembolic events (blood clots): A SMALL to MODERATE excess number of healthy women having cesarean delivery experience a blood clot.

Anesthetic complications: Limited evidence suggests that a MODERATE excess number of healthy women having cesarean delivery may experience complications with anesthesia compared with similar women having spontaneous vaginal birth.

Major infection: Limited evidence suggests that a MODERATE to LARGE excess number of healthy women having planned cesarean delivery experience major puerperal infection compared with women having or planning vaginal birth.

Wound infection (cesarean or genital): A LARGE excess number of healthy women having cesarean delivery have wound infections compared with women planning vaginal birth.

Hematoma (cesarean or genital): Limited evidence suggests that a LARGE excess number of healthy women having cesarean delivery have wound hematomas compared with women planning vaginal birth.

Length of hospital stay: Planned cesarean delivery increases length of hospital stay by at least 0.6 to 2 days compared with planned vaginal birth.

Hospital readmission: A MODERATE to LARGE excess number of healthy women having cesarean delivery require readmission to the hospital.

Problems with physical recovery: With the exception of the presence of hemorrhoids, which are more common with vaginal birth, a LARGE to VERY LARGE excess number of women having cesarean delivery experience problems with physical recovery, including general health, bodily pain, extreme tiredness, sleep problems, bowel problems, ability to carry out daily activities, and ability to perform strenuous activities, compared with women having spontaneous vaginal birth.

Chronic pelvic pain: More women experience chronic pelvic pain after cesarean delivery than after vaginal birth, but the excess number cannot be calculated from the studies examined.

The effect on babies delivered via cesarean

Respiratory distress syndrome: When birth occurs before 39 weeks, more babies born by cesarean than by vaginal birth experience respiratory distress syndrome (RDS), but the excess number cannot be calculated from the studies examined.

Pulmonary hypertension: Limited evidence suggests that a MODERATE excess number of babies delivered by elective cesarean may develop pulmonary hypertension.

Asthma: Cesarean delivery increases the likelihood of developing asthma in childhood, but the excess number cannot be calculated from the studies examined.

Type 1 diabetes: Cesarean delivery increases the likelihood of developing Type 1 diabetes in childhood, but the excess number cannot be calculated from the studies examined.

Allergic rhinitis: Cesarean delivery increases the likelihood of developing childhood allergic rhinitis, but the excess number cannot be calculated from the studies examined.

Symptomatic food allergy: Limited and conflicting evidence suggests that cesarean delivery may increase the likelihood of developing food allergy in childhood, but the excess number, if any, cannot be calculated from the studies examined.

Obesity: Limited evidence suggests that a LARGE excess number of children delivered by cesarean may be obese at age 3.

The complications resulting in cesarean delivery

Operative maternal injury: Among women having first delivery via cesarean, a MODERATE number of women experience bladder puncture, and a SMALL number experience bowel injury or injury to a ureter.

Surgical cuts to the baby: Limited evidence suggests that a MODERATE number of babies are cut during cesarean delivery.

Re-operation: Limited evidence suggests that a MODERATE number of women having cesarean delivery require re-operation.

Persistent pain at the site of the cesarean incision: Limited evidence suggests that a LARGE to VERY LARGE number of women still experience pain at the incision site 6-10 months or more after cesarean delivery.

Cesarean scar endometriosis: Limited evidence suggests that a SMALL to LARGE number of women having cesarean delivery develop cesarean scar endometriomas.

Cesarean scar ectopic pregnancy/early placenta accreta: Some women becoming pregnant after cesarean will experience a cesarean scar ectopic pregnancy or placental implantation within the uterine scar, but the number cannot be calculated from the studies examined.

Dense intra-abdominal adhesions: Limited evidence suggests that a VERY LARGE number of women develop dense adhesions after cesarean delivery.

Complications unique to vaginal birth

Anal sphincter injury: A LARGE number of women experience anal sphincter injury at vaginal birth.

Perineal or genital lacerations of any degree: Exclusive of episiotomy, a VERY LARGE number of women experience trauma to the perineum or genitals at vaginal birth that requires suturing.

Persistent perineal pain: Limited evidence suggests that a LARGE number of women experience persistent perineal pain lasting at least six months with spontaneous vaginal birth, and a VERY LARGE number of women experience perineal pain lasting at least six months after instrumental vaginal delivery.

Potential effects of cesareans on women in future pregnancies and births

Voluntary infertility: A LARGE to VERY LARGE excess number of women choose not to conceive again after cesarean delivery.

Placenta previa: A SMALL excess number of women with first delivery by cesarean develop placenta previa in the next pregnancy, but the excess number cannot be calculated from the studies examined. A LARGE excess number of women develop placenta previa after two or more prior cesareans.

Placenta accreta: A SMALL excess number of women with first delivery via cesarean develop placenta accreta in the next pregnancy. A LARGE excess number of women develop placenta accreta after multiple prior cesareans.

Placental abruption: A MODERATE excess number of women with first delivery via cesarean have a placental abruption in subsequent pregnancies.

Hysterectomy: A MODERATE excess number of women with prior cesarean delivery require an urgent hysterectomy during the next delivery admission compared with women with only prior vaginal birth. Limited evidence suggests that the excess increases with subsequent pregnancies.

Uterine rupture: A MODERATE excess number of women will experience uterine rupture with prior cesarean delivery compared with prior vaginal birth.

Intensive care admission: Limited evidence suggests that a LARGE excess number of women with prior cesarean are admitted to intensive care at the next delivery compared with women with prior vaginal birth.

Hospital readmission: Limited evidence suggests that a MODERATE excess number of women with prior cesarean are readmitted to the hospital after discharge at the next delivery compared with women with prior vaginal birth.

Conclusion

This data supports efforts for women to strive to avoid a c-section and reduce the rates for future generations.  

I do believe it is worth noting that not all women will be able to deliver their babies vaginally - a c-section, in some cases, is the only safe option for delivery. Because of this, we must continue to give all women support and encouragement no matter how a baby was born – avoid judgment and condemnation at all costs.

We must unite as one front to effectively alter the rate of cesarean surgery for all women and our daughters.

Because how you give birth can not only effect a mother, but also her baby and future babies – it is important to gather information and understand the options before being faced with situations/events that will increase risk of surgical birth.

Here are a few ways to reduce the chances of having a c-section:

Ask hard questions – Don’t be afraid to interview prospective OBGYNs. Ask them what their c-section rate is. Don’t be afraid to ask whether the doctor is knowledgeable about natural/low intervention childbirth. Be inclined to contact the local hospital and ask for recommendations!

Plan ahead and be clear – Don’t plan on presenting your birth plan the day of your actual birth! Discuss your plans during all your prenatal visits. Be very clear and continue to re-affirm your goals to everyone involved.  

Don’t be induced – This one is important! As tempting as it might be in those last few weeks and days of pregnancy, never ask to be induced or give into the pressure to electively induce (unless medically needed).

Hire help – Hiring a doula has been known to increase the chances of vaginal and low-intervention birth. If you can’t afford one, still contact one and they may offer other payment arrangements. Many doulas believe that everyone woman should be supported during labor – no matter what.

Eat like you mean it – So you are serious about avoiding a c-section? Well, consider striving for the most optimal food and supplements. Eating nutrient rich foods help women reduce the risk of having a c-section (predominantly because it reduces your likelihood of gaining too much weight during pregnany – despite the common saying, you are NOT eating for two). Also consider something more then just a prenatal vitamin. Studies have been published illustrating that higher levels of vitamin D consumed during pregnancy may enhance your chances of a vaginal birth.  Sign me up!

Reference:

Read the report here-

Childbirth Connection (2012) Vaginal or Cesarean Birth: What is at stake for women and babies? New York: Childbirth Connection.  

Check out more on-

Transforming Maternity Care

Executive Summary

The Best Birth Plan

This is by no doubt the best birth plan I have ever read. It is posted on Timothy McSweeney’s Pyramid Schemes Contain Obtuse Angles blog.

It is hilarious, witty, and fun – enjoy!

Dear

Hospital Staff:

Thank you and congratulations for being on shift for the birth of our child. The following sets forth our wishes for our stay. If a medical emergency requires you to deviate from this plan, please refer to “Jamie and Jeff’s Emergency Birth Plan.” (Tab J) Please note: Jamie is RH Negative and BPA-free.

Philosophy

While we do not have a traditional “philosophy” of “childbirth,” we have been heavily influenced by orthodox Wholefoodism and the “(d)well baby/good design” movement. We believe strongly in the power of the female body and a long-term night nurse. We are opposed to torture/gluten. In the event you are ever unsure how to proceed today, please ask yourself, “What Would Gwyneth Do?”

Environment

We would like mood lighting, like on Virgin America.

The following people, who were with us at conception, will again be in the room with us today: Jeff’s mom; Jeff’s sister; Jeff’s sister’s friend, Melanie (plus 2); Jeff Koons.

Please provide WiFi so we can check what you say against Wikipedia and our favorite mom blogs.

Music is very important to us, as music was playing in the Mongolian yurt when we first made love.

In lieu of a traditional hospital gown, Jamie would prefer to be dressed like Zooey Deschanel in 500 Days of Summer.

Please avoid any use of the words “pulsate,” “soiled,” or “octo” in the delivery room.

Prep

Jamie would prefer no enema or shaving of pubic hair. If shaving is necessary, she would prefer something in the shape of a vuvuzela. Jeff’s pubic hair should NOT be shaved.

Jeff would like an IV.

Labor

Please generally avoid procedures that are totally unnecessary or excruciatingly painful.

Jamie would like Jeff to do the pushing whenever possible.

We have chosen a Doctor (“Mr. Cooper”) because he shares our desire for a natural, low-intervention birth. Mr. Cooper will deliver the baby via Skype from his home in Taos

.

If Jamie starts to sob uncontrollably during labor, please turn off The Notebook. In the event the crying continues, please administer the following drugs to Jeff (per Mr. Cooper): Darvocet, Diamorphine, Vicodin, Medical Marijuana.

If induction is necessary, Jamie would like to try the following before Pitocin is administered: walking, stretching, flipping over, rolfing, online browsing, nipple stimulation and/or sexual intercourse.

Nipple stimulation should be done by the resident Jamie met on the tour who looks like Benjamin Bratt.

Delivery

We strongly prefer a girl.

If you have not already done so, please now take a few minutes and read Early Admission: How to Deliver an Ivy League Baby!

Jeff will remain in the squatting position throughout delivery.

When the crown of the head appears, please turn down the music as Jeff will be reading aloud from Be Here Now by Ram Dass.

Please, no texting while suctioning.

Jamie would like a mirror so that she can see the horrible expression on her face if it’s a boy.

IMPORTANT: if the baby appears to be black, please immediately escort Jeff out of the room and bring in Jeremy Rayburn from the 5th Floor waiting area.

In the event of a Cesarean, please practice Western medicine.

Post-Birth

We are interested in the following preschools: St. James, The Schoolhouse at Cedar Point, or Kidsplace. Willow Glen is ONLY a backup.

Jamie would like Jeff circumcised.

Please do not cut the cord until we are through the toddler years.

We would like the baby certified organic by Oregon Tilth.

Please don’t put the baby on a scale, as we don’t want her to have the same body image issues as her fat mom.

We would like to donate the placenta to the people of the Gulf

Coast.

We ask that the baby be bathed in our presence, in the delivery room, in San Pellegrino.

Per Mr. Cooper, do not feed the baby mussels.

Per Gisele Bundchen, do not give the baby a bottle (i.e. chemicals) for at least 6 months.

If the baby must be taken from the room because of a medical emergency, we would like Jeff to accompany the child. (In this scenario, Benjamin Bratt would stay with Jamie. Please maintain mood lighting and insert the CD in Jamie’s handbag labeled, WHEN JEFF LEAVES.)

We will not be vaccinating our baby. Please vaccinate all other babies on this floor.

Namaste,
Jeff and Jamie