Should You Get an Epidural?
Alice Callahan
Having a baby is an inherently painful proposition. The birth process is punctuated with a series of decisions made around minimizing risks and coping with the pain, which is unpredictable in both intensity and duration. An epidural can help with pain, but how does that change the risks that you and your baby face?
I speak from experience here. I've had two vaginal births, the first after an exhausting 30 hours of difficult labor and the second after eight hours of what I'd characterize as mostly manageable discomfort.
In that first labor, I eventually joined the majority of people giving birth in the U.S. and opted for an epidural. Here's how it works: an anesthesiologist inserts a needle, followed by a catheter, into the "epidural" space just around the spinal cord (video). Pain medication is then infused, pleasantly numbing the nerves signaling pain from the uterus and birth canal. Most epidurals today include low doses of both a local anesthetic and an opioid, which in combination allow for pain relief while maintaining some motor function so that you can at least change position and bear down to push.
Epidurals are consistently the most effective method of managing labor pain, but like every drug and medical procedure, they also come with some risks. For example, about one in ten people with epidurals will have a drop in blood pressure, which can be corrected with fluids or medication given through an IV. Epidurals also increase the chance of having a fever during labor, especially when it's prolonged, and this can lead to antibiotic treatment. About 1% of people that get an epidural end up with a bad headache, and others experience nausea, vomiting, and itchiness. (Contrary to popular belief, there's no evidence that epidurals cause a long-term backache.)
Epidurals are consistently the most effective method of managing labor pain, but like every drug and medical procedure, they also come with some risks.
Epidurals also change the experience of labor. "An epidural does provide significant pain relief, but it comes as a part of a package," says Lisa Kane Low, president of the American College of Nurse Midwives and associate professor in the School of Nursing at the University of Michigan. For example, you'll need an IV in case of low blood pressure, and hospitals often require continuous fetal monitoring to keep tabs on the baby, too. This means you'll usually be stuck in bed for the duration of labor, which might be just fine if you want to catch up on a favorite show before the baby comes but less fine if you're hoping to be up and about, able to try things like laboring in a tub or on a yoga ball.
Does an epidural make you more likely to have a c-section?
The question of how epidurals affect the course of labor is complicated and controversial. Observational studies, which look at large groups of people who chose to have epidurals or went without, consistently find that women with epidurals have longer labors and are more likely to have C-sections or help from forceps or vacuum to get the baby out. But observational studies can only show correlations between variables; they can't show that one caused the other.
Cynthia Wong, professor and chair of the Department of Anesthesia at the University of Iowa, explains it this way: "On rainy days, more people carry umbrellas. It does not mean the umbrellas cause rain. Similarly, more women who have epidurals have cesarean deliveries. It does not mean the epidurals cause cesareans."
For example, you're probably more likely to ask for an epidural if you're having more pain, and a more painful labor could be caused by a bigger baby or one that isn't positioned well for birth. In this case, there's already a higher risk of C-section, caused by the very same factors that might make you choose an epidural in the first place.
It's a classic chicken or egg problem. Which came first, the epidural or the difficult labor? A randomized controlled trial, in which pregnant volunteers are randomly assigned to receive an epidural or not, could sort out this question, but few people are eager to participate in a study where they leave decisions about pain relief up to researchers. It would also be unethical to deny study participants pain relief for the sake of science.
On rainy days, more people carry umbrellas. It does not mean the umbrellas cause rain.
So, researchers have had to find other ways to study this question. For example, they've done randomized controlled trials in which all participants receive pain medication, but some get epidurals and some get IV opioids. A 2011 Cochrane review combined the results of 27 trials with more than 8,000 births and found no difference in the rate of C-section, and a 2017 meta-analysis agreed. Other studies have looked at historical data, comparing the C-section rate in hospitals just before and just after they started offering epidurals in the 1980s and 1990s, and these find no bump in the C-section rate when epidurals became an option.
The 2011 Cochrane review did find that epidurals were linked to use of forceps or vacuum during birth. However, that analysis included studies from as far back as 1974 with lots of variation in the drugs and concentrations used. Modern epidurals use lower doses, and with these, there seems to be no increase in forceps or vacuum use.
Do epidurals lengthen labor?
Because of the concern that it's harder to push effectively with an epidural, obstetricians sometimes turn it off when it's time to push (called the second stage of labor). That bothered Philip Hess, director of obstetric anesthesia at Beth Israel Deaconess Medical Center in Boston. "As an anesthesiologist, it's always frustrating because we have a tendency not to want to see people in pain," he says.
So, he collaborated with researchers at a hospital in Nanjing, China, to do a randomized controlled trial where all the women had epidurals but half were switched to saline at the start of second stage of labor. There was no difference in the duration of labor or in the incidence of C-section or forcep deliveries. The only effect of turning off the epidural was that women were less likely to be satisfied with pain relief.
When Hess's study was published last month, some media coverage seemed to jump to the conclusion that epidurals don't affect the length of labor at all, but the study wasn't designed to answer that question. All the women had epidurals in the first stage of labor, and the effects of the drugs don't disappear the minute it's turned off. In fact, there were no differences in how the women in the two groups rated their pain during the pushing phase, although the saline group showed an increasing trend in their pain scores as time went on. But if epidurals do slow labor, it's possible that effect was in play in both groups of women.
Those with epidurals had to push for a median of 112 minutes compared with 47 minutes for those without epidurals.
Hold Up, There's No New Study About Epidurals and Total Length of Labor
Do epidurals prolong labor? Read the headlines this week and you'd think we finally answered that…
Other data on this question are conflicting, and again, dose may matter. Older trials using more variable doses find an increase of about 15 minutes in the length of second stage, while newer studies of low-dose epidurals don't show an effect.
Observational studies, on the other hand, usually show a very strong correlation between epidurals and longer labors, but these are complicated by the same issue as the C-section studies. "When you see the association in a group of 1,000 women or 100,000 women between epidural pain relief and longer labor, it's only because a labor which is going to be longer tends to produce more pain, so women are more likely to ask for pain medication," Hess says.
But Wong thinks there's a good chance that epidurals really do slow labor a bit, and Aaron Caughey, professor and chair of the department of obstetrics and gynecology at Oregon Health & Science University School of Medicine, agrees. Caughey was one of the authors of a 2014 observational study that found labors with epidurals were quite a bit longer. For example, among first-time moms with vaginal deliveries, those with epidurals had to push for a median of 112 minutes compared with 47 minutes for those without epidurals. But, he points out, "The goal isn't necessarily a short labor. The goal is an enjoyable experience to some degree."
And sometimes, an epidural may even help a stalled labor move forward. "Some people may come in, they may be doing beautifully, coping really well for a long period in their labor, and they may have an attitude of 'I never want an epidural.' But then, as things unfold, they may find themselves in a long labor, exhausted, needing rest, because that becomes the barrier to their progress," says certified nurse midwife Kane Low. In this situation, pain relief and the ability to rest may be just what you need. (On the flip side, Kane Low says that if you have your heart set on an epidural, it's good to be prepared to use other pain management techniques in case the anesthesiologist isn't available right away or your labor moves faster than anticipated.)
Do epidurals affect breastfeeding?
One other long-standing concern about epidurals is that they might affect breastfeeding, because the opioids in epidurals can cross the placenta, perhaps making newborns less alert for learning to breastfeed. Wong and collaborators published a randomized controlled trial earlier this year that is reassuring on this front. They tested several different concentrations of opioid in epidurals and found no effect of dose on breastfeeding rates.
What's the bottom line?
The bottom line is that epidurals come with a major benefit (pain relief) and some small but real risks, including low blood pressure, fever, and headache. They don't seem to cause an increase in C-sections or difficulty breastfeeding, and they may or may not lengthen the pushing phase of labor. An epidural is an excellent tool for managing pain, but whether to use one is an individual choice, and one that might change depending on how things go. With my first baby, getting an epidural allowed me to sleep after hours of painful contractions, and maybe that rest gave me the energy to finally push my big baby out. With my second, labor was faster and easier, and an epidural just didn't feel necessary. In both, I was grateful to have the option if it was needed.
Alice Callahan is a health and science writer based in Eugene, Oregon. She has a PhD in nutrition and is the author of The Science of Mom: A Research-Based Guide to Your Baby's First Year.
Tommy P
My wife had an epidural for our only child, and one of her loose goals for childbirth was to avoid an epidural. The whole day was a blur to both of us, but after a decent period of time the doctor and my wife agreed it was time to induce labor. About an hour after taking the hormones and related drugs to induce, she started having painful contractions. She endured another hour or two of painful contractions before she acquiesced (to herself) and had an epidural.
As a husband and father that was probably the worst hour or two of our lives, I have never seen my wife in more physical pain. Nothing is worse than holding your wife's hand as she endures pain and there's not a thing you can do to help her out.
I guess the point of my story for women and men out there: be open to everything that may occur during childbirth, and be supportive of one another. My wife and I have heard stories of both women and men shaming mothers for getting an epidural, as if it's unnatural or something along those lines. That is so wrong it makes me irrationally angry.
My son is nearly 2 now and both he and my wife are happy, healthy, and enjoying our lives, and that's all that should really matter.