Many women begin their pregnancy feeling sure about wanting an unmedicated birth or an epidural, but for some, pregnancy raises the question, “should I get an epidural?” Others begin to question the use of epidurals when they first learn about epidural side effects, or hear about epidural side effects from another new mom.
To have or not have an epidural is one of many factors that affects birth experience. A thoughtful approach to decisions about pain management is important! Ultimately your gut-feelings and insights into yourself will be the surest guideposts pointing you towards a positive decision for you. There is not one approach that is right for every woman or every situation. Each family must figure out for themselves what type of experience will lend itself to creating the strongest foundation for their family. Whatever you decide, research clearly shows that your ownership of the decision and a sense of personal control and choice are fundamental to positive emotions after the fact. Make your choice in confidence and for yourself and your baby. This decision is not one to make out of fear or to please others.
In order to make a thoughtful decision for yourself and your baby, it’s imperative that your personal questions and fears are addressed so that you are informed and confident. This article will be an orientation to the following:
- Common Reasons for Choosing or Declining an Epidural
- Epidural Benefits
- Epidural Side Effects
- Impact of Epidurals on Labor
- Impact of Epidurals on Breastfeeding
- Epidurals and Birth Satisfaction
I hope it answers some of the questions you may have about epidurals. After the informative part of the article I provide a pain medication planning guide that will help you reflect on your personal feelings regarding pain and your options for pain relief during birth. This planning guide is also useful for women who do not want to use pain medications during birth but feel like everyone seems to think they are crazy. Your answers to some of the questions will help you articulate, to yourself and possibly to others if necessary, why you feel drawn to birthing without anesthesia.
Table of contents:
- Common Reasons to Choose or Decline an Epidural
- Are epidurals safe?
- What are the impacts of epidurals on labor?
- Do epidurals affect the baby?
- Do epidurals take away all of the pain?
- Is the pain unbearable without an epidural?
- Do epidurals affect breastfeeding?
- Do epidurals affect bonding?
- Do epidurals affect postpartum recovery?
- Are epidurals related to postpartum depression?
- Are most women glad they had an epidural?
- What do you recommend?
Common Reasons to Choose or Decline an Epidural
Contrary to the annoying and patronizing public opinion, women do not decline epidurals “to win a medal.” They aren’t out to prove anything, and they don’t feel birth is a competition. When doula clients hire me and express their desire for a natural birth, I always ask them to share their story with me by asking questions such as, “When did you decide you would like an unmedicated birth?” “What draws you to it?” and/or “Why is it your preference?”
Everyone has their own story of women they have known or books they have read, or simply a feeling they have always had, which has led them to want to birth naturally. The most common reasons I hear relate to the desire to eliminate the chance of experiencing a side effect of epidurals or the need for additional interventions. Many of these women have known someone personally who developed a spinal headache or chronic backache after birth. A few recount stories of epidurals leading to c-sections. The next category of common reasons involve wanting to experience and feel the birth of their baby. Some women feel that giving birth is a right of passage or a unifying female experience. They believe that women have been birthing for generations and have traditionally found strength through the work of giving birth. They want the timeless experience of working through the challenge of birthing followed by the exhilaration at the moment of birth, the end of the pain, and the rush that often follows the birthing experience. The third category of reasons relate to a fear or dislike of needles or a preference for minimal medical intervention. Many of these women tell me that they never take drugs for a headache, and they would rather work through short term pain knowing it’s not dangerous, rather than go through the process of getting an IV, an epidural, a catheter, and continuous monitors. Sometimes I hear concerns that the epidural will affect the baby or breastfeeding. Some women don’t want to lose the ability to stand and walk and shower or have a water birth. Women have shared many other unique reasons with me as well. Some personal reasons relate to cultural or spiritual beliefs, and some women are not eligible for epidurals based on health history or current medications.
I ask the same questions when I work with clients who are choosing an epidural. Some of these women have a story of women they have known or a book they have read, but the vast majority assume that everyone would want an epidural and haven’t considered otherwise. The most common reason to choose an epidural is to experience less pain during birth. Women say they want to get through birthing in as calm and easy a manner as possible, and are grateful that pain is no longer a necessary part of the experience. Many women feel less fear of birth knowing that an epidural will likely provide excellent pain relief. Some women express a deep desire to be clear-headed during birth, and to be able to watch their birthing in a mirror while feeling calm and present. Some describe wanting to have pleasant joyful memories of the day their baby was born. Some of my clients express self-knowledge and feel that they have a low pain tolerance, and others have beliefs that pain relief is a fundamental right. Again there are personal reasons beyond those represented here, often related to social history or unique health situations.
Are epidurals safe?
Different families have different definitions of “safe.” Or to put it another way, each family has their own comfort level with particular types of risk. What one family considers safe may make another family uncomfortable.
The best answer to this question is to share, to the best of our knowledge, epidural side effects and the actual risks associated with an epidural during labor, so that each family can make their own judgements about safety. Research is tricky as there are many factors to consider and birth is not a context in which the variables can be carefully controlled. There is also great variation among different hospitals and different anesthesiologists. In spite of those limitations, research does provide a general risk picture. The experiences of nurses, midwives, doctors, doulas, and parents can also provide insight.
Limitations of Research
It is important to realize that epidural technique, the drugs used, and dosages used are constantly changing. Statistics from one study may shed little insight on an epidural administered differently. The anesthesiologist and your doctor or midwife is the best source of up-to-date information and speciﬁcs related to your personal health history. A care provider who offers you evidence-based information, honest and open opinion free of defensiveness, and who uplifts and afﬁrms you and your commitment to being an involved, informed parent is an incredibly valuable resource.
The International Childbirth Education Association (ICEA) reports the following statistics in their 2002 position paper on epidurals:
- 28-30% have a 20-30% drop in systolic blood pressure which may lead to fetal distress. Treatment may include ephedrine, which can cause accelerated or variable fetal heart rates.
- Accidental puncture of the dural lining occurred in 5%, 4.28%, and 1.3% in different studies. Rates are provider-dependent. The side effect is an intense headache that may last from 1 – 6 weeks, or in rare cases much longer. Spinal headaches are often positional meaning that they are intense when in vertical positions, so moms must lay flat to manage the headache. Spinal headaches can be treated with a blood patch.
- 14.5% develop a fever greater than 100.4 degrees. This leads to evaluation of the newborn to rule out sepsis, which includes separation of baby and mother, blood work, antibiotics, and possibly a spinal tap. Increased temperature can also cause newborn seizures, lower Apgar scores, increased rates of resuscitation, and an increase in instrumental deliveries and C-sections.
- Epidural side effects such as itching and nausea range dramatically according to what type of epidural technique and what narcotics are used.
- There is a 3-10% increase in reported backache when comparing mothers who had an epidural with mothers who did not.
- 3.3% have problems with urinary retention.
- 1 in 1400 women will have problems with an incorrectly placed or migrating catheter resulting in a high block. This can cause a drop in blood pressure, loss of sensation, inability to speak, loss of consciousness, and maternal respiratory problems.
- 1 in 3000 women will have an accidental puncture of a vein or inwards of the epidural space. This can cause a loss of consciousness, convulsions, cardiac arrest, or maternal respiratory problems. These conditions are life threatening in 1 in 4000 women.
- Studies agree that the use of Pitocin is at least twice as high, some studies suggest far higher, when epidurals are used.
- Significantly more babies present in a malposition, which makes pushing more difficult, and increases instrumental delivery and C-section.
- Nearly a 30% increase in instrumental deliveries (vacuum extraction or forceps delivery).
- Nearly twice the rate of 3rd and 4th degree tears.
What are the impacts of epidurals on labor?
People often ask me if epidurals lengthen labor. According to the ICEA, the first stage of labor (the opening of the cervix) is an average of 30% longer with epidurals than without. My gut feeling given my experience and this statistic is that, rather than a subtle slowing of most labors, epidurals have little or no effect on the length of labor for many women, speed labor for a few, and create long delays for a handful, resulting in the average above. In my experience as a birth doula I have seen epidurals that seem to dramatically lengthen labors, epidurals that seem to have no effect on timing, and epidurals that seem to speed things up or encourage how labor progress.
Epidural’s shortening of labor seems to happen during births where there is a great deal of physical tension and/or mental fear. Epidurals decrease the level of adrenalin hormones, which is helpful if adrenalin levels are so high that they are compromising the function or release of oxytocin. During the first stage of labor (the opening of the cervix), high adrenaline levels are counter productive for labor. However, during the second stage (pushing), these very same hormones naturally surge through the body and create great physical strength which helps women push effectively. Adrenalin also helps mom and baby emerge from birth alert and fully energized. Epidurals have a depressive effect on both the positive and detrimental functions of adrenalin in birth. Therefore, moms who receive epidurals in labor often feel more worn out and depleted after birth that those who birth without them.
The contexts in which epidurals seem to slow things down are far more elusive for me. I’m not able to make a prediction about when this occurs. Research indicates that epidurals received earlier in labor, before 3 cm of dilation, can stall or slow contractions. I have been present several times when epidurals were administered around 5 cm to women who were laboring quickly with all appearances that they were going to have a very straightforward labor. Upon administration of the epidural, contractions virtually disappeared. They slowed to a rate of less than 5 per hour. In approximately half of the births I have witnessed where this occurs, contractions never really came back. In the other half, contractions became regular again after a few hours. Pitocin was used during the births when contractions slowed dramatically after administration of an epidural, which was effective for many of my clients and not for a few others who eventually had c-sections. In my candid conversations with L&D nurses, it seems that most have also witnessed the slow down or cessation of contractions after epidurals. I think it is important that pregnant women know that while the research shows that epidurals only mildly lengthen labor and do not cause c-sections, many birth professionals feel they occasionally witness long delays and an increased need for surgery.
Interestingly, more then once I have been present during conversations between clients and doctors where clients are assured that epidurals do not lengthen labor. A few hours later, the very same doctor will offer reassurance when contractions slow or stop by saying, “That’s OK – we expect to see that after an epidural is administered. They will come back.” Accurate information about the impact of epidurals on labor seems to be hard to come by.
Epidurals do lengthen the pushing stage for many women, but typically not to the point that vaginal birth is compromised. This is due in part to the decrease in adrenalin and to the lack of sensation which would naturally coordinate voluntary pushing with the action of the uterus. I believe it is also due to the woman’s comfort. If in pain, the stakes of extending this period are quite high, whereas someone who is not feeling pain may be more patient with the process. There is also an increase in malpositioning of the baby which delays labor until the positioning is resolved. However, epidurals are sometimes a great aid during the pushing phase by facilitating the relaxation of the pelvic area if tension or fear are high.
Why decide ahead of time?
- Complete preparation for laboring with or without an epidural is different. Knowing what you plan on will help you learn and visualize the speciﬁc tools you need in your situation.
- The inﬂuences of the staff and feelings of fear or exhaustion during your birth will have a large impact on decisions you make during labor, which decreases your ownership and sense of control over your decision. This in turn decreases satisfaction and increases doubt, especially if anything unwelcome arises.
- If your decisions is “wait and see” you will still be well served in labor by the detailed factors that you come to understand now.
What if I change my mind?
Making a decision before birth does not limit your options on the day of birth. Birth has many unknowable characteristics and factors. You are always free to change your mind. Do not hesitate to plan because you feel you cannot know everything that will happen or how things will feel. Do not hesitate to plan because you don’t want to look foolish later. Planning organizes and strengthens your preparation. Planning to have an epidural if “X,” but not if “Y” is a plan! You ﬁll in the blanks with whatever experiences or situations make sense to you.
The clearer your reasons are ahead of time, the clearer it will be if your situation warrants a different choice. If you change your mind in labor it is likely to be an empowering experience of self-awareness and self-support or of positive surrender, rather than a tentative, fear-based or pressured decision.
Do epidurals affect the baby?
Many women choose epidurals over other pain relief because little medication reaches the baby. Some studies refute this claim by measuring narcotics in the baby’s bloodstream, but it is widely accepted that your baby will be exposed to far less medication if you have an epidural as compared to IV administration of drugs.
Other ways that the baby is affected are through the effects on maternal physiology. Some of those changes – such as a change in blood pressure or temperature – have the potential to greatly affect the baby, creating fetal distress.
Newborns have also been found to have decreased motor and orientation skills, increased fussiness, and breastfeeding difficulties when epidurals are administered. These results were most apparent for 24 hours after birth, but were still measurably different one month after birth. This is not to say that babies cannot breastfeed if you have an epidural, but rather that in fine and subtle ways it is possible that an epidural undermines the ease of breastfeeding. Breastfeeding complications are multi-faceted with many inter-related factors, making a clear cut cause and effect statement about epidurals and breastfeeding impossible.
Epidurals do impact the hormones released during birth. Hormones cross the placenta and have complex roles in newborn awareness and behavior, as well as maternal behavior. With an epidural there will be fewer endorphins and decreased adrenalin during birth. My article on birth hormones explains more about the role of these hormones.
And finally, it is important to remember that longer labors, Pitocin, instrumental deliveries, and C-sections have effects on babies as well, and that there is an association between epidurals and an increase in these interventions. A full discussion of these effects requires a great deal of background education, and many of them are discussed only in theoretical work rather than in quantitative studies. In short, they include compression of cranial nerves, changes in the pulsatility of oxytocin, and myo-facial trauma, all of which may effect a wide range of emotional and physical aspects of a baby’s wellbeing.
Do epidurals take away all of the pain?
Epidurals are extremely effective pain relief for the majority of women. They usually mask nearly 100% of the contraction pain, and they take the edge off of the pressure and stretching experienced during pushing. Only 5% of women with an epidural report inadequate pain relief.
55% of women do experience break through pain, which is when pain is felt in one small area of the body while the surrounding area remains numb. Break through pain can move around, and it is usually transient.
The most common unexpected pain experienced with an epidural is an intense onset of pain during the final pushes before birth.
Early labor hurts more than most women expect. Because it is best practice to place epidurals after active labor is established, most women will experience pain during childbirth with an epidural. The pain will likely be manageable without any special preparation for birth, though knowing some techniques for working with the pain of contractions rather than fighting them is beneficial for all women.
Is the pain unbearable without an epidural?
Labor pain is experienced differently for different women, as well as during different labors for the same woman. Most women who choose unmedicated childbirth, and prepare for it, find the pain very intense but manageable. Most are very happy with their experience after-the-fact, though in the midst of labor, find it incredibly hard and painful work. Some women experience contractions more as powerful sensations or even as exhilarating, though they are in the minority. Mental reframing has a huge impact on how one experiences labor pain, as do the position of the baby, the force of the labor, previous injury, exhaustion and assurance/confidence vs fear… and probably other factors as well! Desire seems to be one of the largest factors. Where there is a will there is a way! In short, no – it’s not unbearable – for those who WANT to go about it a different way, but it’s not unbearable because of the will not because of the scale of the physical sensation.
Do epidurals affect breastfeeding?
There is a correlation between epidurals and decreased breastfeeding. Even in studies that control for many variables, including how many attempts at breastfeeding are made and when, find that there is at least a 10% increase in formula supplementation in the first 24 hours after birth and a decrease in infant suckling in the first four hours. One study looked at breastfeeding rates 6 months after birth and also found a decrease in breastfeeding correlated with epidural use. See “Do epidurals affect the baby?” for more.
It is important to note that while studies have shown this correlation, the mechanism is not fully understood. There is a study that shows that the levels of oxytocin and endorphins released during breastfeeding remain lower in women who received an epidural for at least 30 days after birth. Another study recorded measurable differences in newborn behavior through one month after birth. These studies point to the possibility of a long-term, subtle, physiological impact of epidurals.
I believe that personal choice is likely a significant factor in the associations between epidurals and breastfeeding duration as well, with those choosing to labor without an epidural having a higher degree of desire to breastfeed.
Do epidurals affect bonding?
I am not aware of any studies looking directly at this question. There are studies that show that women who are well supported and nurtured in labor are more nurturing towards their babies and report increased positive feelings towards their babies. Epidurals do have a natural effect on how deliberately moms are cared for during the labor process, but this effect is certainly within our conscious control. There are other studies that have shown a correlation between satisfaction and positive emotions regarding birth and improved maternal fetal bonding. As you can read below, there is a lower rate of satisfaction with birth among women who have epidurals.
Interestingly animal studies show a very clear effect of epidurals on bonding. In fact, sheep who receive an epidural during birth will reject their young and refuse to care for them.
Studies regarding the impact of epidurals on hormones shed light on those animal studies. Epidurals work by blocking the pain signals between the body and the brain, and those very signals have a great effect on hormones. Oxytocin release is decreased after epidural administration, and there is a major decrease in endorphins and adrenalin. As well as causing uterine contractions, oxytocin is known as the love hormone. It is involved in all kinds of loving exchanges. Endorphins create an altered state of consciousness during birth which is completely absent in women who receive an epidural. These hormones work on the same brain receptors that create states of dependency or addiction. You can see how changes in these hormone systems would create major changes in behavior in animals who do not share our rational, logical brain or our social nature. Obviously the correlations between animal behavior and human behavior are extremely limited… but they do shed light on the biological boost towards parenting behavior that may be decreased by epidural administration. Adrenalin is one factor that stimulates baby behavior that we find so endearing – dilated pupils causing that beautiful newborn wide-eyed expression of wonder, and increased strength and alertness which allows them to turn to the sound of our voice moments after birth. Studies measuring the levels of these hormones in humans do show differences both during labor and in the month following birth between people who do and do not receive epidurals.
In my experience, devoted parents are just that – devoted, responsive, and loving – regardless of whether or not they had an epidural. My clients who choose epidurals do sometimes have more questions and look to me for more answers regarding their babies than do my clients who labor without pain medications. They also seem to have a higher level of anxiety about the physical resilience of their babies. But that certainly doesn’t apply to everyone who had an epidural. I wouldn’t attribute it to bonding, but rather to the surreal nature of birth with an epidural. Epidurals aim to separate you as a person from the physical experience of birth as effectively as possible. I think sometimes it takes longer for the reality of it all to “sink in” than when you felt every aspect of birth in your flesh and bones. That surreal nature doesn’t seem to affect connection to the baby, but it can cloud gut instincts, especially for those who tend to make decisions with their intellect and are less practiced using their gut.
Do epidurals affect postpartum recovery?
The research that would indicate a yes to this question are the studies that suggest higher rates of 3rd and 4th degree tears, instrumental deliveries and C-sections. Difficult births take more out of you, and incisions of any kind take time to heal. There are also studies that report a moderate increase in back pain, and there is a small risk of a spinal headache or allergic reaction.
Interestingly, in births that are straightforward, women with an epidural also report more pain and exhaustion postpartum. My hunch is that epidurals don’t actually affect recovery but rather the experience of it. This may be related to the effects of receiving and recovering from an epidural, but it may also be a matter of contrast. To someone who just experienced all the sensations of birth, the discomforts afterwards are minor in comparison. There is also the hormonal effect, which I suspect is largely responsible. Because of the natural endorphins and adrenaline released in an unmedicated birth, moms who did not receive an epidural have a flood of energizing and feel good hormones. Without those hormones cursing in their blood, mothers who received an epidural feel wiped out after the exertion of childbirth.
Are epidurals related to postpartum depression?
There are studies that show a weak correlation between epidural administration and higher rates of postpartum depression, but in those I have reviewed the correlation was minor or statistically insignificant. Epidurals certainly are not one of the major risk factors for postpartum depression. The correlation between satisfaction with birth experience and control or autonomy during birth are more significant.
Are most women glad they had an epidural?
The national epidural rate hovers at 70-93%. 69% of women who had an epidural say they would use one again. In comparison 90% who labor in a tub of warm water said they would again. Research shows that rates of satisfaction with the birth experience are higher among women who have had unmedicated labors. The highest rates of satisfaction with the birth experience are found among women who had one-on-one labor support from a doula or midwife, followed by those who utilized immersion in a warm tub of water, and then by those who used self-hypnosis.
What do you recommend?
This question only finds a place in this article because it is indeed often asked of me!
I truly recommend that you make your own personal decision. In my doula practice, all of my clients are very happy with their decisions, both for epidurals and for unmedicated labor. As a woman who has given birth, both options make sense to me. I personally did not use an epidural during my three births, all of which were straightforward uncomplicated labors. Natural birth is an incredible experience, one that has been very positive for me. At the same time the pain is remarkable and during every birth I have moments where I understand, 200%, why a woman would prefer to have an epidural. I think the key is in an informed and honored choice and support through whatever experience you face.
Guard against decisions made from guilt or fear. Many women choose epidurals because they are afraid they can’t do natural birth. If you want to, and have support, you can! Some women choose unmedicated births because they feel its best for the baby and that they are a “bad mom” if they just get an epidural that is not necessary. This won’t lead to a positive decision, and will not serve you or your family! In my opinion, the risks of an epidural are clearly within the range we as a society tolerate as acceptable. By societal standards epidurals are safe and a responsible choice. I believe there are many strong and loving families that choose both epidurals and unmedicated labors. I do think epidurals open up chance for complications that no one would choose for their family, but not in drastic numbers that families may not be comfortable with. I also find that there are circumstances when epidurals are a very valuable tool.
If you feel afraid of what people will think of you regarding either choice take ownership of your right to make this decision for yourself! It’s natural to feel these fears in a culture that sensationalizes both the pain and the power of birth. Don’t let these fears limit you. You are not “crazy” and you deserve total autonomy around such a personal experience. There are positive ways to prepare your body, mind, and spirit for birth in any of its many forms. Seek out support for what you truly wish for.
The type of experience you want to have in birth is a major consideration. Epidurals dramatically change the emotional and physical experiences in labor and delivery. When women labor without medication for pain, the experience is intense and demands total focus. Your spouse or partner will be completely drawn into the process and into helping and supporting you. You will feel everything and know just what to do and when. It is a challenging climax experience with an extremely high emotional context. You will never forget it, and the story of when you gave birth will be vivid. Experience with epidurals is much more varied. Once your epidural is placed you will likely be in your normal mental state and comfortable enough to play cards or watch a movie. You will follow the directions of your nurse or doctor to know when and how to push. Sometimes hard work or pain at the end creates focus or intensity similar to natural birth, and sometimes pain relief is so complete that through the moment of birth there is little sensation and total calm. Your emotional involvement, and your spouse/partner’s, come more from a conscious decision to focus on the birth of your baby and less from the imperative of the pain.
Whatever you choose, embrace it. Inform yourself before deciding, and then when your reasons are solidly in place you will most likely be very happy with your decision. Plan well for it – understand how to optimize labor given your context. Autonomy, affirmation, respect, celebration, and above all, love, make for a very positive birth that you can carry in your heart for a lifetime.
Get Ready! Look at the Should I Get An Epidural? Planning Guide.