Epidural anesthesia is the most commonly used and requested method of pain relief for women giving birth in hospitals today. Because it so effectively numbs the pain of contractions, women believe it is the best option and it has become an expectation of many women before they've even experienced labor. Women who have received epidurals see them as a quick fix and are seldom given fully informed consent prior to the procedure. There are many possible side effects and complications, not to mention the entire cascade of medical interventions which often ensue following such a procedure. Women who have had less than favorable experiences with their epidurals often wonder why they were not told about the potential adverse outcomes. The best practice is to fully educate yourself prior to any medical procedure and become an informed consumer. The following information is intended to provide you with a comprehensive guide to everything you need to know about epidural anesthesia, including the benefits and the often untold risks.
Janelle Durham, 2002
What is an epidural?
A catheter is placed into the lumbar region of the back, between vertebrae into the epidural space. Medication is injected, typically by continuous pump infusion. May be a “caine” anesthetic or a narcotic analgesic (Fentanyl or morphine), or a combination of these.
Some side effects may vary depending on exactly which medication is used. See Simkin, Whalley, and Keppler for an excellent discussion.
Provides pain relief in abdomen, back, buttocks, perineum, and legs.
The most common type of pain relief. Statistics vary widely by hospital, but rates may be as high as 75-90% of births.
Benefits of Epidurals: why would you ask for one in the first place?
Effective pain relief (for 90-95% of women).
Reduced pain related to contractions and to interventions such as pitocin, forceps, episiotomy, cesarean.
Mother can remain clear-headed, think and converse normally, and can rest, often even sleep for a few hours while her cervix continues to dilate.
May relax pelvic floor muscles, allowing cervix to dilate fully. (This is especially true if mother is experiencing a lot of anxiety because of the pain.)
Side effects of narcotics are reduced when they’re given by epidural rather than I.V. because less drug is needed.
Can lower blood pressure, which may be helpful for hypertension.
How is an epidural administered, what equipment is involved, and what are the side effects?
After you request an epidural, the nurse will call the anesthesiologist. May take 15-60 minutes: Women have described this period as “the longest 30 minutes of my life”. This is because they had already decided the contractions were overwhelming, and asked for relief, and it’s hard to wait for that to come. This is the time to use all the comfort measures at your disposal. Meanwhile:
You get into bed; you won’t be able to walk around after the epidural. Most hospitals also say no more food and water from this point on.
An IV is started, and extra fluids are given to reduce the chance of a drop in blood pressure. The I.V. also allows for easier administration of medications such as pitocin. Pitocin augmentation is about 3 times more likely in epidural labors
One of the common side effects of epidural is dystocia (slowed labor progress).Contractions are decreased in strength and/or frequency. Body may stop producing oxytocin. Early labor may slow or stop
Of 8 studies reviewed by Thorp, 7 suggest epidurals are associated with longer first stage labor. This is typically treated with pitocin.
9 of 10 studies reviewed report a significant association between epidural and longer 2nd stage labor. (This may lead to instrumental delivery or c-section.)
Usually a blood pressure cuff is placed to regularly monitor blood pressure. If blood pressure drops (as it does for 12% of women): more fluids, oxygen or medications.
Temperature is checked regularly: there is a 14.5% chance of fever over 100.4 w/ epidural;chance increases after 4 hrs or more with epidural. After 7 hours with epidural, fever increases by up to 1ºC (1.8º F) per hour.
If you develop a fever, medical staff works on the assumption that you have an infection: treatment for infection may begin. (May involve antibiotics for mom; 48 hours of observation, blood culture, and spinal tap for baby.)
External Fetal Monitor is placed to monitor baby’s condition.
If mother develops a fever: Baby’s heart rate may become rapid. Baby may develop a fever (30% chance with epidurals)
If the mother is given pitocin: contractions can get too long and too strong, reducing baby’s heart rate.
If mom’s b.p. drops: decreased fetal heart rate and decreased oxygen supply.
Mild to severe fetal distress in 10-15% of babies after epidural. Generally these changes don’t affect the baby’s health at birth (as measured by APGAR scores), but signs of fetal distress can lead to c-section…
One thing you can do to help: after an epidural, lie on your side rather than your back; may decrease fetal distress.
Prepping and placing the catheter can take 15-25 minutes. Mother is sitting, or lying on her side, with her back arched. Her back is cleaned with betadine and draped with sterile towels. Local anesthetic is injected, then a large needle is pushed through the skin, then the epidural needle is placed, then catheter is placed, and the needle removed. The mother must remain completely still for insertion, even through severe contractions. The catheter is securely taped to the mother’s back, and medication is begun. May take 15-45 minutes to reach full effect.
Urinary catheter is placed. (Can’t sense need to urinate, and full bladder may slow labor.) Bladder function may not return to normal for a day or two after birth.
Mother may need oxygen mask, due to decreased respiratory rate.
With narcotic epidurals, side effects may include moderate to intense itching, difficulty in urination, nausea and vomiting.
Shivering is present in 10% of laboring women. With epidurals, the incidence raises to 33%. Although harmless, it may cause concern for mothers.
Headache. During labor, or chronic headaches in the months after birth.
Support people tend to move further away from birthing moms after epidural: One study showed that instead of being inches away on average before the epidural, they’re feet away afterwards. When the mom is no longer experiencing physical pain, they may assume she no longer needs support; some women report feeling emotionally abandoned by people moving away at this point.
Time for the Birth
- Can you feel the urge to push? Generally not. Medical staff will check cervix to tell you when to start pushing; and will watch monitor to tell you when a contraction comes so that you can push with the contraction.
- Can you push as effectively with an epidural? No. Abdominal muscles are weakened: normal pressures exerted during second stage are 120-135 mm Hg, with an epidural, they barely reach 100 mm Hg. Also, you can’t use your voluntary muscles as well to aid in the pushing, and you can’t move into the most effective positions (i.e. squatting)
- Does the baby rotate as well into the correct position if mom has had an epidural? No. Amongst non-epidural mothers, only 4% had a posterior baby persisting into second stage; after epidural, 19% failed to rotate.
As a result of these factors, there’s an increased risk of: forceps, vacuum extractor, and c-section. Of 24 studies reviewed, 22 studies showed a significant association between epidural and instrumental delivery; other 2 suggested an association, but it was not statistically significant. With narcotics, instrumental delivery: 3-7% With epidural: 15-53%
Thorp referred to some studies where the epidural medication was stopped once the mother reached 8 cm dilation, so that sensation would return for second stage labor. You may wish to consult with your caregiver about whether this practice is currently recommended.
Increased Risk of Cesarean
In a review of 15 available studies, 12 suggested a significant association between epidural and c-section. Risk of c-section generally found to be 2-3 times more likely with epidural.
An influence on this is what point in labor the epidural was administered. One study found that cesarean rates were 11% if epidural was given at 5 or more cm dilation, 16% at 4 cm, and 28% at 3 cm. Another study was even more striking, finding that cesarean rates increased to 26% when epidural was given at 4 cm, dilation, 33% at 3 cm, and 50% when the epidural was given at 2 cm dilation. So, the longer you can wait to have an epidural, the better.
Possible Effects After the Birth.
Backache. 10% of new moms develop a backache for the first time that lasts at least 6 weeks. Among women who’d had epidurals, the number jumps to 18%. This may be due to poor positioning during birth: women with epidurals may not be able to sense discomfort when they are in a position which is straining muscles, so support people need to pay attention to keeping mom in a comfortable, healthy position.
Medications cross the placenta and may have subtle side effects on the baby, including more difficulty in self-soothing, subtle changes in reflexes.
Decrease in maternal oxytocin during labor may interfere with oxytocin release after birth. Bonding and milk letdown reflexes may be decreased.
Some uncontrolled studies have been done, which aren’t conclusive due to lack of controls, but interesting nonetheless: unmedicated mothers reported that their babies were more sociable, more rewarding, and easier to care for. Unmedicated moms were more responsive to their babies’ cries. Women who had epidurals smiled less at their infants
Statistics cited are from “Epidural Anesthesia in Labor: An Evaluation of the Risks and Benefits” by Thorp and Breedlove, Birth, June 1996. This was a literature review article, which summarized the results of numerous studies involving thousands of births. Other information from: Pregnancy, Childbirth, and the Newborn by Simkin, Whalley, and Keppler (1991 edition). Maternity & Women’s Health Care by Lowdermilk, Perry, and Bobak (6th Edition, 1997). Family-Centered Maternity and Newborn Care by Celeste R. Phillips (Fourth edition, 1996). “Epidural Epidemic” by Dozer and Baruth, Mothering, July-August 1999. “What no one tells you about Epidurals” by Penny Simkin; “The Cascade of Interventions” by Pam England; and Epidural’s Effects on Babies” by Beverley Lawrence Beech, in Mothering, March-April 2000.
Epidural anesthesia has become
increasingly popular for childbirth. The popular
book, What to Expect when You’re Expecting,
for example, portrays epidurals as perfectly
safe. The risks, however, may be greatly underplayed.
Epidurals and pain relief
For the most part, epidural
analgesia does effectively relieve labor pain.1
Obstetrical anesthesiologists continue to state
that epidural analgesia has other, potentially
catastrophic, adverse effects but, with safe
clinical practice, these problems are extremely
rare. We will suggest in the material that
follows that these complications are not extremely
rare, and that women are not receiving adequate
informed consent about what these complications
are and their accompanying frequency. Nor are
they being offered any serious alternatives
to epidural anesthesia. Despite this, anesthesiologists
such as Eberle and Norris argue that specific
anaesthetic techniques ... or obstetrical management
can limit or eliminate these risks of epidural
labour analgesia. What must be remembered for
any technical procedure, is that it is studied
in major academic centers where highly skilled
professors supervise residents and all outcomes
are monitored closely. The actual practice,
however, takes place in smaller institutions
by less qualified individuals so that the actual
complication rates of any procedure (obstetric,
cardiac, pulmonary) are always higher than
what are found in studies.
Overall complications rates
for epidural anesthesia
A general estimate of the overall complication
rate of epidural anesthesia is 23%.2
1. Effects of epidurals on
When the dose is too large or
when it sinks down into the sacral ("tailbone")
region of the body, the perineum and the vagina
are anesthetized. Anesthetic is intentionally
injected into this area late in labor to deaden
all sensation. When it "accidentally"
happens earlier in labor, the muscles of the
pelvic floor are prematurely relaxed, thereby
interfering with the normal flexion and rotation
of the baby's head as it passes through the
birth canal. This interference can lead to
abnormal presentations which are more dangerous
for the baby or to what is called "failure
to descend," an indication for Cesarean
Thorp, et al3 studied 711 consecutive
nulliparous women at term, with cephalic fetal
presentations and spontaneous onset of labor.
They compared 447 patients who received epidural
analgesia in labor with 264 patients who received
either narcotics or no analgesia.
The incidence of cesarean section
for dystocia was significantly greater (p <
0.005) in the epidural group (10.3%) than in
the nonepidural group (3.8%). There remained
a significantly increased incidence (p <
0.005) of cesarean section for dystocia in
the epidural group after selection bias was
corrected and the following confounding variables
were controlled by multivariate analysis: maternal
age, race, gestational age, cervical dilatation
on admission, use of oxytocin, duration of
oxytocin use, maximum infusion rate of oxytocin,
duration of labor, presence of meconium, and
The incidence of cesarean section
for fetal distress was similar (p > 0.20)
in both groups. There were no clinically significant
differences in frequency of low Apgar scores
at 5 minutes or cord arterial and venous blood
gas parameters between the two groups. They
concluded that epidural analgesia in labor
increases the incidence of cesarean section
for dystocia in nulliparous women.
Frequently the epidural is so
effective that it eliminates uterine contractions.
The nerves which tell the uterus to contract
are all anesthetized. The uterus becomes quiet
and must be driven artifically with the hormone
oxytocin (Pitocin or Syntocinon).
As the cervix becomes fully dilated
and the head descends, the woman (in a normal
birth) feels pain and pressure in the lower
pelvis and rectum. The last injection of anesthetic
during the process of epidural anesthesia occurs
after the head has rotated and come down onto
the perineum. Higher concentrations of anesthetic
are used to assure perineal relaxation. Sometimes
the mother is sat upright or at least at a
45 degree angle to be certain that the anesthetic
will descend to the sacral nerve roots. When
the sacral nerve roots are blocked, the woman
looses the urge to push.
After controlling for potentially
confounding variables with multiple logistic
regression analysis, Adashek, et al4 found
that epidural anesthesia was an independent
risk factor for cesarean birth among women
over age 35 (R = 0.195, p < 0.001).
At the 1997 meeting of the American
Society for Anesthesiology, a press release
was issued about four studies involving a combined
total of more than 22,000 women claiming that
labor epidural analgesia does not increase
a woman's risk of having a cesarean delivery.5
Three of the studies were presented at the
annual meeting of the American Society of Anesthesiologists.
The fourth appeared in the September 1997 issue
of the medical journal of Anesthesiology.
“The findings have significant
implications for physicians, patients and insureres,”
said one of the reserchers, Steven T. Fogel,
M.D., an anesthesiologist at Washington University
School of Medicine in St. Louis. "Some
physicians and insurance companies limit patient
access to epidurals because they srongly believe
thta epidurals can prolong labor, "Dr.
Fogel said. "Delaying or withholding an
epidural forces the pregnant woman to suffer
needlessly and does not lower the cesarean
Each year, about one-million women choose epidural
blocks for safe and effective pain relief durig
A study by Dr. Fogel and colleagues
at Washington University analyzed labor and
delivery data on 7,000 patients. The researchers
compared the cesarean rates among first-time
mothers during the 12 monts before and the
16 months after epidural analgesia became available
on request at the hospital. They found no significant
differences in cesarean section rates before
and after the services introduction. "Epidural
analgesia did not stop normal labor or cause
cesarean deliveriew, because the rate of cesareans
did not change," Dr. Fogel said.
Women may still require cesarean
delivery following epidural blocks, but no
direct cause-and-effect relationship has ever
been established. "labor epidural anlagesia
can be associated with , but does not cause,
cesarean section delivery," Dr Fogel said.
"An abnormal labor can produce extreme
pain for mothers, and this pain leads women
to ask for epidurals," he said.
"Our study has the advantage
of following cesarean rates before and after
the introduction of a popular epidural service,"
Dr Fogel said. "Since patient demographics
and cesarean section rates did not change,
we can safely and accurately conclude that
the total number of cesarean delieveries performed
was not affectred by the availability of epidural
Similar findings emerged from
an analysis of data on more than 13,000 first-time
mothers who gave birth between 1989 and 1995
at St. Luke's Roosevelt Hospital Center, a
teaching hospital of Columvia University in
New York City.
The analysis showed that themother's
age, the baby's birth weight and use of the
labor-inducing drug oxytocin increased the
women's risk for cesarean sections. "Not
only was epidural analgesia not a significant
risk factor but it was associated with slightly
decreased cesarean section delivery risk."
anesthesiologist David J. Birnbach, M.D., said.
By relieving pain, epidural analgesia
may help some patients relax and this relazation
could facilitate labor, Dr. Birnbach said.
"We're not suggesting the technique will
prevent cesarean sections," he stressed,
"but in our practice, epidurals are clearly
not a cause." In addition, the use of
epidural analgesia almost doulbed at the hospital
during the five years studied (from 37% to
68%) but the percentage of cesarean sections
deliveries did not increase, Dr. Birnbach said.
A third study at Boston's Beth
Isreal Deaconess Medical Center reviewed the
labor and delivery records of more than 2300
women who recieved ultra-low dose solutions
of epidural medications. The ultra-low dose
epidurals allow many women's albor to proceed
comfortable, Stephen D. Pratt, M.D., said.
For women requireing more apin relief, additional
medication can be given by the same epidural
The Boston study showed that
women who needed addtional pain relief beyond
the ultra-low dose wre more likely to have
cesareans. Women who needed more than two additional
doses were twice as likely to require a cesarean
section as those who do not. "The slow,
abnormal labor that leads to cesarean section
is more painful than normal labor and therefore
requires stronger epidural medication,"
Dr Pratt said. "Epidural do not cause
cesarean sections. Rather women who have abnormal
labor may be in more pain and therfore are
more likely to need an epidural and stronger
The above three studies were
retrospective studies done in choice situations/hospitals
that had actively taken a new approach to reducing
cesarean sections as well as hospitals that
maintain such high cesarean section rates that
the comparisons would be insignificant due
to cesarean rates of over 30%.
The only prospective study was
the fourth one, conducted at the University
of Texas Southwestern Medical Center in Dallas.6
Seven hundred, fifteen women of mixed parity
in spontaneous labor at full term were randomly
assigned to receive either epidural anesthesia
(EA) or patient-controlled intravenous meperidine
analgesia (PCMA). Epidural analgesia was maintained
with a continous infusion of 0.125% bupivacaine
with 2 pg/ml fentanyl. Patient controlled analgesia
was maintained as 10-15 mg meperidine given
every 10 minutes as desired by the patient
using a patient-controlled pump.
A total of 358 women were randomized
to receive epidural anesthesia and 243 (68%)
complied. Similarly, 357 women were randomized
to receive patient-controlled analgesia, and
259 (73%) complied with that protocol. Five
women randomized to PCMA requested epidurals.
Based upon an intent to treat analysis, there
was no difference in the rate of cesarean deliveries
between the two groups (EA, 4%, 95% CI: 1.9-6.2%;
PCMA, 5%, 95% CI: 2.6-7.2%. Women in the epidural
group reported lower pain scores during labor
What is amazing is that this
study was used to argue that epidurals did
not increase risk for cesarean birth. What
is lacking, of course, is a reasonable control
group, such as a doula. When one looks at the
amazingly high amounts of meperidine that women
could self-administer, it is no wonder that
so few requested an epidural, since they could
hardly be expected to be very alert. A woman
could receive 90 mg of meperdine per hour.
In actuality, the average amount of meperidine
a woman self-administered was 200 mg with the
highest amount being 500 mg. To give a sense
of the amounts being given here, routinely
in the emergency department, for treating ureterolithiasis
(kidney stones), which most women agree is
a more severe pain than labor, I would rarely
administer more than 150 to 200 mg of meperidine
over 12 hours. The average length of labor
during which these women received their meperidine
was under 12 hours. No one has asked the question
of how such a massive dose of meperidine would
affect the cesarean rate.
The authors stated, "Patient-Controlled
intravenous analgesia is widely used in the
United States to manage postoperative pain,
although use during childbirth has been limited.
One concern is newborn respiratory depression
from increased narcotic administration to the
mother. Many women in our study used more than
200 mg of meperidine during the course of their
labor, but only 3.4% of infants were given
naloxone to reverse respiratory depression.
The mothers were visibly sedated but were invariably
arousable and none experienced respiratory
Since neither of us have never
had to give an infant naloxone in over 1000
deliveries, we wonder what the indications
would actually be. We suspect these infants
were quite depressed to receive naloxone. Our
experience with patient controlled analgesia
is that the reason the patient stops pushing
the button is that she gets so high a dose
that she falls asleep. I suspect the mothers
were more compromised than the authors think,
but none had to be intubated or artificially
ventilated, therefore, “none experience
The authors also under-emphasized
the fact that all patients were enrolled at
the same time in an aggressive program to reduce
cesarean birth, consisting of:
No use of electronic fetal monitoring,
even for epidurals (except for one
test strip on admission), thereby
necessitating nurse auscultation
of the fetal heart rate and one-on-one
patient care, both well known to
reduce the cesarean rate.
No patient admitted to the hospital
before 4-5 cm of cervical dilation,
also known to lower the cesarean
No drugs or epidurals until the woman
was 5 cm dilated, also known to reduce
the cesarean rate.
All births attended by CNMs, which
is known to reduce the cesarean rate
by one-third of what obstetricians
would do. For example, a study from
Los Angeles County-USC Hospital showed
a 4% cesarean rate in a 95% Hispanic
population when they were attended
Use of a black and Hispanic population.
In an editorial discussion, the authors,
themselves, comment on black and
Hispanic populations having historically
lower cesarean rates
The authors' real conclusions are this: If
you do everything possible to reduce the cesarean
rate for all patients, and then, if you compare
epidural anesthesia with high dose, self-administered
narcotic analgesia, there is no difference
in the cesarean rate. This is not really a
very outstanding conclusion, though the popular
press read this result as saying epidural anesthesia
is now proven safe and unlikely to increase
the cesarean rate (without addressing the question,
Some infants (0.8%) in the epidural
group also required naloxone. Two transfers
to NICU occurred in the epidural group and
3 in PCMA group.
Looking just at those who had
epidurals vs. those who didn't, epidurals prolonged
the first stage of labor and increased the
incidence of oxytocin administration. Fever
developed in more women during epidural anesthesia.
There was no difference in the number of cesareans
in the epidural vs. the PCIA group (the range
from 3% to 7% cesarean rate).
Regarding other complications,
24% of women having epidurals had fever compared
to 6% in PCMA. Nine percent had forceps with
epidural compared to 3% with PCMA. There was
a15-19% range of meconium during labor (not
different between groups), which we find rather
high. There was a rate of 1.2-1.8% of infants
suffering meconium aspiration (not different
between groups), but also rather high in our
2. Significant low blood pressure
Significant low blood pressure
is a complication of epidural anesthesia.1
The ways that epiduralized patients must lie
accentuate this. Their position is limited
since they are essentially paralyzed people
for the duration of the epidural. Hypotension
occurs among almost one-third of patients with
serious hypotension occurring about 12% of
Maternal hypotension is a major
risk for the baby. The epidural blocks the
nerves which regulate blood pressure. It causes
the blood in the body to pool, keeping it from
being pumped around the body in the proper
manner. The arteries dilate and relax their
usual, necessary level of tension, making it
difficult for the heart to pump blood to the
baby. These changes lead to a decrease in the
output of the mothers heart. Less blood per
unit time can reach the placenta and therefore
The baby is completely dependent
on the mothers heart to pump blood to the placenta
to satisfy its needs. All of its oxygen comes
across from the placenta. All of the food for
its brain and other organs comes across the
placenta. Brains cannot live without a relatively
constant supply of oxygen and glucose. Without
this they become damaged.
A good blood flow is needed to
the uterus between contractions so it can get
fresh oxygen. During the contraction, blood
flow to the uterus is cut off by the muscles
contracting. When the contraction stops, the
uterus must quickly refill with fresh blood
containing oxygen for the baby. If the amount
of blood flowing to the uterus is reduced,
the baby may not be able to get the oxygen
it needs. Then what is called fetal distress
may occur. The babys system does not get enough
oxygen and goes into distress. Its blood retains
excess acid, the oxygen levels go low and tissues
and vital organs begin to fail from excess
acid, lack of oxygen and lack of fuel
Animal studies have shown that
lack of oxygen to the baby (called fetal hypoxia)
can cause significant damage to the baby’s
brain even without the pH of the baby’s
umbilical cord blood being affected.9 (The
pH of the babys umbilical cord blood at birth
is usually used as an indicator of whether
or not fetal hypoxia has occurred.)
Severe low blood pressure can
also result from compression of the mothers
blood vessels (aorta and vena cava) since all
mothers must lie essentially flat on their
back after epidural anesthesia (they cannot
feel or move their back, pelvis and legs).10
3. Fetal distress:
Fetal heart rate decelerations
can occur following the use of epidurals.1
Babies can develop fetal distress after epidural
anesthesia.11 This may be caused by the mothers
blood pressure getting so low that blood cannot
be adequately pumped into the uterus to deliver
oxygen to the baby. As we mentioned above,
epidurals make it difficult for the muscles
in the arteries of the lower body to respond
and to keep blood adequately flowing through
the body. The ability of the heart to respond
to changing needs of the body is impaired.12
Eberle and Norris1 suggest that [i]nduction
of maternal analgesia may transiently alter
the balance between factors encouraging and
discouraging uterine contraction. A temporary
increase in the uterotonic effects of endogenous
or exogenous oxytocin may then produce a tetanic
contraction with subsequent decrease fetal
oxygen delivery and resultant fetal bradycardia.
Most babies of mothers receiving
epidural anesthesia develop episodes of slow
heart rate (bradycardia).13 While this does
not usually affect the healthy baby, it can
be disastrous for the baby that is alreay compromised
from some other problem (often unknown to the
Adverse effects on the baby indicative
of insufficient oxygen reaching the baby (late
decelerations) can occur. These changes may
also result from a toxic effect to the baby
of the local anesthetic given in the epidural.
The transient low blood pressure
which always occurs after epidural anesthesia
has been found to lead to significantly lower
the babys blood pH.14 This indicates excess
blood acid, usually meaning that the baby is
not getting enough oxygen. Anesthesiologists
don’t think that this makes any difference
in the babys outcome, but we suspect, if we
studied babies already at risk for other reasons,
we would find that epidural significantly worsens
compromised babies and may lead to a Cesarean
birth when the baby might have otherwise tolerated
a vaginal birth. We suspect that more detailed
research would identify a group of babies who
would have tolerated unmedicated, normal birth,
but who are unable to handle the added stress
of the epidural, leading in the worst causes
to death or permanent disability.
4. IV Cannulation:
Accidental injection of the anesthetic
solution into the blood stream can occur and
can cause the mother to twitch, have convulsions,
or lose of consciousness. Seizures can occur
from the toxic effects of the anesthetic agent
entering the blood stream.15 Local anesthetic
toxicity occurred among 12 women in 1000 epidurals.16
5. Trauma to blood vessels:
Trauma to blood vessels can occur
as a result of epidural anesthesia.17 In one
study, bleeding in the spinal column and unintentional
placement of the catheter into an artery or
vein occurred 0.67% of the time (67 women of
every 1000 epidurals).18 The catheter actually
escapes outside of where it is supposed to
go 1 to 6% of the time.19
Hemorrhages can occur around
the spinal cord and even within the skull following
epidural anesthesia.20 These were associated
with persistent backaches or headaches. Failure
to treat these problems usually results in
permanent paralysis. Surgery must be performed
within 8 hours of the onset of paralysis or
the prognosis is poor. Chronic subdural hematoma
has resulted from epidural anesthesia and has
even presented as post-partum psychosis.21
6. Punctured dura:
The actual dura may be punctured
as a result of epidural anesthesia. Because
of the large size of the needle used, severe
headache may also result. Dural punctures have
been found to occur about 1.8% of the time.22
Unintentional dural puncture occurred in 61
of 1000 epidurals in a University hospital
(resulting in spinal anesthesia).23
An infection can develop at the
site of injection. Bacterial meningitis can
occur from contamination during placement of
the epidural.24 An abscess can also form at
the site where the epidural catheter is placed.25
Backache is a common complication.
Back pain commonly occurs after epidural anesthesia
(18.9% of the time27 ). Upper back pain can
happen at some distance from the site where
the epidural is injected.28 The back pain can
last very long-term.29 Nineteen percent of
women had long-term backache after epidural
anesthesia.30 It probably results from a combination
of its effects on the nerves and from extreme
postures and stretching that occurs after the
epidural during labor.
Low back pain after epidural
anesthesia for childbirth is also frequently
9. Broken catheters:
Occasionally the catheter has
broken and a small piece is left in place.
It usually causes no ill effects.
10. Abnormal uterine contractions:
Uterine contractions can become
weaker and less frequent. An oxytocin infusion
is then necessary to improve labor and produce
good strength contractions Mothers having epidurals
have longer labors and have a higher incidence
of the use of oxytocin than mothers having
There are important risks of
giving oxytocin also. Administration of this
hormone to the mother during labor can cause:
Dangerously high blood pressure.
Abnormal heart rhythms.
Nausea and vomiting.
Sustained uterine contractions which
last too long and result in the baby
going into distress from lack of
oxygen. When this is too severe,
the uterus can rupture. The epidural
can mask the strength of the uterine
contractions so that no one knows
that how strong they are, making
uterine rupture more possible.
Hemorrhage around the brain.
Retention of water leading to convulsions
Bleeding in the pelvis and increased
incidence of postpartum hemorrhage.
Death of the baby.
Jaundice of the baby.
11. Second stage labor effects:
With large doses the patient
loses the desire and the ability to bear down
and push. This results in an increased use
of forceps and vacuum extractions over women
having unmedicated deliveries.33
12. Inadequate pain relief:
The epidural is generally inadequate
7.1% of the time leading to supplementation
with intravenous pain medication 4.0% of the
time and a general anesthetic 3.1% of the time
(in one study).34
13. Accidental spinal anesthesia:
When an epidural accidentally
turns into a spinal anesthetic, many complications
Dysfunction of the bladder is frequent
Occasionally numbness and tingling
(paresthesias) of the lower limbs
and abdomen develop, and sometimes
there is a temporary loss or diminution
of sensation in these areas.
Unilateral footdrop (paralysis of
the muscle that lifts the foot) has
Permanent nerve damage (conditions
called chronic, progressive adhesive
arachnoiditis or transverse myelitis)
can occur. These lead to paralysis
of the lower parts of the body.
Deaths have been reported.
Increased incidence of forceps deliveries.
The reliability of spinal anesthesia
with 5% hyperbaric lignocaine was studied among
30 patients undergoing elective Cesarean. Twelve
patients had hypotension and four developed
severe postspinal headaches. The block progressed
to the C2 dermatome in four patients and was
associated with dysphagia. This was totally
unpredicted and was thought due to altered
cerebrospinal fluid dynamics in late pregnancy.35
14. Maternal heart attack
or spinal cord ischemia:
The lack of ability of the heart
to pump blood around the body (from low blood
pressure or pooling of blood) can become so
severe that a heart attack occurs or the spinal
cord will suffer damage from not enough blood
Asthmatics can get suddenly worse
during epidural anesthesia37 with more wheezing
and inability to breath.
16. Medication interactions:
A hidden danger of epidural anesthesia
is its interaction with medications (prostaglandins)
commonly used to soften the cervix and start
labor. The use of prostaglandins is common
at hospitals and creates a potentially dangerous
situation in which the usual medications used
to treat low blood pressure during labor will
no longer work.38
17. Interactions occur with
As an example, women who have
migraines can have more visual disturbances
18. Maternal fever:
Maternal fever and even the severe
condition called malignant hyperthermia (dangerously
high fever) can result.40 41
19. Respiratory arrests:
Mothers can stop breathing (respiratory
arrest)42 43 and can experience other breathing
difficulties.44 Greenhalgh* reported a 19 year
old obstetric patient who had a respiratory
arrest shortly after receiving intrathecal
sufentanil and bupivacaine as part of a combined
epidural/spinal technique for pain relief.
20. Other neurological disabilties:
Other neurological disabilties
(including a condition called Horners syndrome)
can develop along with hoarseness (from even
just one dose of epidural anesthetic).45 Clayton46
reported an incidence of Horner's syndrome
during epidural anesthesia for elective Caesarean
section of 4%. The incidence of Horner's syndrome
with epidural anesthesia for vaginal delivery
was 1.33%. They found it impossible to predict
which patients would develop a Horner's syndrome.
Even the nerves to the face can be blocked,
sometimes temporarily, sometimes permanently.47
Tremors and shakes can occur.48 49
Paresthesias (persistent tingling
from sensory nerves) occurred in 0.16% of patients
in one study (1.6 per 1000) with an incidence
of persistent neuropathy of 0.04% (4 per 10,000).50
Four of these patients had a neuropathy which
eventually resolved. In another study 3.0%
of patients had tingling of the hands or fingers,
while 26 of almost 5000 women had persistent
tingling or numbness in the lower back, buttocks
Dizziness and fainting can become
a problem after epidurals. One study found
these symptoms persisting in 2.1% of women.52
21. Nausea and vomiting:
Twenty to 30 percent of women
experience nausea after epidural anesthesia,
while 3 to 7% have vomiting.53
22. Allergic conditions:
A dangerous allergic condition
with shock (called anaphylaxis) can occur.54
The woman develops a red rash (erythema), itches,
and her lungs fill up with fluid (pulmonary
edema). Excessive lung fluid is also found
in the babies in these cases.55
23. Heart problems:
Mothers can experience excessively
slow heart rates (bradycardia), heart block
in which the electrical activity of the chambers
of the heart become dissociated and sometimes
even stoppage of the heart (cardiac arrest).56
Headache after epidural is a
persistent problem that is more pronounced
in younger patients.57 One study found its
incidence after epidural anesthesia to be 4.6%,
significantly more often than women not having
epidurals.58 It usually occurs from the effects
of puncturing the dura. Headache can also occur
from air getting into the spinal fluid (called
an iatrogenic pneumocephalus). The air is introduced
into the spinal fluid and column when the test
dose is given that is assumed to be in the
extra-dural space. When the person giving the
epidural feels a loss of resistance to the
injection of air, this is when a pneumocephalus
can occur. The patient that was described complained
immediately of severe headache on both sides
of her forehead followed by vomiting. The baby
had to be delivered by Cesarean with general
anesthesia. The patients headache resolved
in 24 hours after Cesarean.
Of 34 women with spinal headache
(from 4766 epidurals), nine had long-term disability
from headache. Five of these were from accidental
dural puncture and four occurred after accidental
25. Motor blockade:
Epidural anesthesia can produce
motor blockade, resulting in temporary paralysis,
even of respiratory muscles.60
26. Use in VBAC:
Epidurals are sometimes used
with women desiring VBAC. Leung, et al.61 studied
the maternal and fetal consequences of uterine
rupture during VBAC. They concluded that significant
neonatal morbidity occurred when > or =
18 minutes elapsed between the onset of prolonged
deceleration and delivery. In 106 cases of
uterine rupture at their institution between
Jan 1, 1983 and June 30, 1992, seven charts
were incomplete and excluded; of the remainder,
28 patients had complete, 13 patients had partial,
and 58 patients had no fetal extrusion into
the maternal abdomen. Maternal characteristics
or intrapartum events were not predictive of
the catastrophic extent of uterine rupture.
There was one maternal death. Complete fetal
extrusion was associated with a higher incidence
of perinatal mortality and morbidity.
27. Technical considerations:
Epidural anesthesia is a technical
procedure that requires significant skill to
place correctly. Many papers document the technical
aspects of this procedure which are not insignificant.
For example, 23% of epidural catheters inserted
more than 2 cm into the epidural space required
manipulation. Epidural catheters inserted 8
cm within the epidural space were more likely
to result in iv cannulation. Epidural catheters
inserted 2 cm within the epidural space were
more likely to become dislodged. Epidural catheters
inserted 2 to 4 cm within the epidural space
required replacement more often than catheters
inserted deeper. 62
28. Herpes simplex assocation:
Epidural analgesia is associated
with recurrence of herpes simplex blepharitis
after cesarean section when epidural morphine
Case Examples (mild problems)
Here is an example of a 30 year old woman having
her first baby who was admitted to the hospital
at 2 cm dilation at 11:05 pm.64 By 4:30 am,
she was 4 cm dilated with her waters broken
and requested epidural anesthesia. Her mother
and her husband were in attendence coaching
her. The epidural was started at 5:01 am and
within 30 seconds, the patients heart rate
began to climb steadily and precipitously from
88 to 174, levelling off at that rate.
The certified registered nurse
anesthetist (CRNA) discovered that the patient
had previously experienced heart palpitations:
when stressed or with heavy exercise. She had
begun to feel mild nausea and dizziness. Oxygen
was administered and an iv drug (adenosine)
was given. A second dose followed five minutes
later. The abnormal heart rate (a supraventricular
tachycardia) returned to normal and the woman
had a normal vaginal delivery within 6 hours
of this episode. This occurred presumable from
a sensitivity to medication placed through
the epidural catheter. When complications such
as this occur, fetal scalp electrodes are usually
placed to monitor the babys EKG. The therapy
sometimes causes severe hypotension.
A case has been reported in which
a 24 year old woman with a past history of
mild backache had an epidural anesthesia. She
had an acute vagal reaction with loss of consciousness
and her head falling forward. Thirty-six hours
later, she complained of severe pains all over
her spine, together with sciatica and spasm
of the muscles on either side of the spinal
column (paravertebral muscles). None of these
symptoms responded to drug treatment. The pain
eventually disappeared after she wore a cervical
collar, taking anti-inflammatory drugs and
having spinal manipulations (what chiropractors
and osteopaths do) It was thought that her
backache was due to what is called a posterior
articular joint syndrome in which the forward
fall of her head strained the posterior joints
of the spinal column.65
Permanent disability from
a. A disabling condition
called spinal arachnoiditis can develop after
epidural anesthesia. Of 6 such women, 3 were
permanently confined to a wheelchair three
years after their initial evaluation.66 None
of these patients had any prior spinal surgery
or trauma or problems with the spinal cord
including previous hemorrhage, infections or
other known causes of arachnoiditis. They had
no neurological symptoms prior to epidural
anesthesia. The diagnosis was confirmed by
a medical test called myelography in all cases.
The epidurals were uneventful and performed
according to standard methods.
Arachnoiditis is probably caused
from the epidural injection of foreign substances
(the anesthetic itself or contaminants in the
solution) into the spinal canal.
Subarachnoid cysts can occur
in the spine from arachnoiditis produced from
the epidural anesthetic.67
b. Paralysis can occur.68
The injection of the local anesthetic into
the epidural space can result in the veins
becoming engorged, the spinal cord suffering
from a lack of oxygen (hypoxia) and the woman
developing acute neurological problems. Some
of these deficits can become permanent.69 Paralysis
can also occur from bleeding into the area
during the epidural injection with the formation
of a pocket of blood pressing on the spinal
cord (hematoma). It can also occur from infection
Cranial nerve paralysis can occur
at quite a distance from the site of the epidural.
This is thought to occur from traction on the
Paralysis can occur from a condition
called anterior spinal artery syndrome after
epidural anesthesia during labor.71 Paralysis
can occur when the blood flow to the spinal
cord becomes so limited that tissue dies. This
is called an infarction. A case report of an
infarction after epidural anesthesia has been
published in which leg paralysis occurred and
did not recover. A loss of sensation to pain
and temperature also occurred to the level
of the mid-chest which partially resolved.72
Of 108 non-fatal complications
in one study, five were associated with permanent
disability.73 These included damage (neuropathy)
to a single spinal nerve, acute toxicity from
the local anesthetic, and problems associated
with accidental puncture of the dura to become
a spinal anesthetic.
Another patient developed paralysis
after epidural anesthesia probably due to the
anterior spinal artery or central arteries
being blocked during the epidural and leading
to death of part of the spinal cord.74
Neuropathy is a condition in
which sensory changes occur (loss of sensation
or hypersensitivity to sensation) with or without
chronic pain. Neuropathy occurs after epidural
anesthesia. It can occur from thrombosis of
an artery from trauma from the epidural injection
or from the catheter. A lack of adequate blood
flow (and therefore oxygen) is called ischemia.
This can cause neuropathy also.75
Deaths from epidural anesthesia
Here are some examples of woman
who have died from epidural anesthesia to illustrate
A healthy, 31 year old woman
having her third child requested epidural anesthesia
and developed an acute condition of fluid in
the lungs (pulmonary edema). She could not
be successfully resuscitated. The baby also
Sudden stoppage of the heart
(cardiac arrest) can occur during epidural
anesthesia.77 78 along with other heart rhythm
changes.79 Sudden cardiac arrest may be caused
by air getting into veins during placement
of the epidural.80
Respiratory insufficiency can
occur and cause death. In one case report,
the patient initially developed pain in the
shoulder-neck region after epidural anesthesia,
followed by fever and an elevated white blood
count. This led to a high-level (arms and legs)
paralysis with an inability to breath. Many
problems then developed with the heart and
arterial system. An abscess was found and the
patient was eventually stabilized with antibiotics.
The patient required chronic mechanical ventilation
and died of recurrent pneumonia after 5 months
of intensive care. The incidence of breathing
difficulties in one study was 0.54%, although
only 5% of those patients required prolonged
artificial ventilation. Total spinal anesthesia
occurred in 0.013% of the epidurals but more
than half of these auses required intubation
and prolonged mechanical ventilation. Partial
spinal anesthesia (sub-arachnoid block) occurred
in 0.04% of the cases.81
Women are almost never given
informed consent for epidurals. Even if they
were just read two paragraphs from the package
insert that comes with the medication used
for epidurals (manufactured by Abbott Laboratories),
they might think twice. The package insert
Local anesthetics rapidly cross
the placenta, and when used for epidural, caudal
or pudendal anesthesia, can cause varying degrees
of maternal, fetal and neonatal toxicity....Adverse
reactions in the parturient, fetus and neonate
involve alternations of the central nervous
system, peripheral vascular tone and cardiac
Neurologic effects following epidural or caudal
anesthesia may include spinal block of varying
magnitude (including high or total spinal block);
hypotension secondary to spinal block; urinary
retention; fecal and urinary incontinence;
loss of perineal sensation and sexual function;
persistent anesthesia, paresthesia, weakness,
paralysis of the lower extremities and loss
of sphincter control all of which may have
slow, incomplete or no recovery; headache;
backache; septic meningitis; meningismus; slowing
of labor; increased incidence of forceps delivery;
cranial nerve palsies due to traction on nerves
from loss of cerebrospinal fluid.
Who would sign a consent if it
included the above language? The degree to
which the facts about the risks of epidural
anesthesia are hidden from women in labor is
Mothers who have a fever are
signficantly more likely to have had epidural
anesthesia.82 Therefor increasing the incidence
of septic workups on newborns and the subsequent
complications of this procedure.
We would hope that pregnant women
would have a more informed explanation of the
risks of epidural anesthesia than what is currently
given, and would suspect that many would make
other choices if true informed consent was
given (before labor, when the woman still has
time to prepare to cope with childbirth pain
in other ways).
Critique of 3 other studies
As we said the study we just
discussed was the only prospective study. The
other three studies are papers not yet published
so we can only comment on the abstracts of
these studies, they were "presented"
at the conference of the American Society of
Anesthesiologists in November of 1997. Presented
means that the paper was talked about at the
conference and has not necessarilly been accepted
by a major medical journal for publication
as of yet and may/or may not be.
1st additional study:
TITLE: Does epidural analgesia protect against
cesarean section in nulliparous patients?
AUTHORS: DJ Burnbach, MD, A Grunebaum,
MD, DJ Stem, MD, B Katgaem MD, MM Kuroda, MPH,
DM Thys, MD
AFFILIATION: Department of Anesthesiology
and Ob/Gyn, St. Luke's-Roosevelt Hospital Center,
College of Physicians and Surgeons of Columbia
University, New York, NY
INTRODUCTION: Recent articles
have suggested that epidural analgesia may
increase the risk of cesarean section. (1,2)
In an effort to evaluate whether epidural analgesia
during labor is associated with an increased
risk of cesarean section at our institution,
we evaluated the labor data of unlliparous
patients who delivered at the hospital between
METHODS: From January 1, 1989
-December 31, 1995, there were a total of 31,670
deliveries at the St. Luke's-Roosevelt Hospital
Center. The 13,203 nulliparous patients who
delivered under the care of an obstetrician
during that period of time constituted the
study population. The following were the independent
variables: type of labor analgesia administered,
patient age, obstetric care provider (private
vs. non-private), birth weight, and use of
oxytocin for stimulation or induction. The
dependent variable was the delivery mode. A
non-hierarchical logistic regression was performed
to determine which of these independent variables
contributed to the risk of cesarean section.
RESULTS: Logistic analysis demonstrated
that the highest risks for cesarean section
were associated with oxytocin induction and
maternal age. As shown in Table 1, other significant
predictors of cesarean delivery were oxytocin
for stimulation, patient status (private patients
were at an increased risk of cesarean section)
and birth weight. Epidural analgesia, on the
other hand, was associated with a slightly
decreased risk for cesarean section. For example,
patients under 30 years of age who were induced
with oxytocin who received epidural analgesia
had a 32% cesarean section rate (230/719) versus
a 39.1% cesarean section rate (70/179) for
the same group of patients who did not receive
an epidural anesthetic. Patients greater than
29 years of age who were induced with oxytocin
and received an epidural had a 45.4% cesarean
section rate (114/251) versus a 58% cesarean
section rate (51/88) for the same group of
patients who did not receive an epidural.
DISCUSSION: Our data support other studies
that have shown an increased risk of cesarean
section with use of oxytocin, increased maternal
age, and private patient status.(3) When controlled
for other variables, the administration of
epidural analgesia was associated with a decreased
risk of cesarean section. Based on our data,
we suggest that epidural analgesia as practiced
at our institution, is associated with a decrease
in cesarean section rate in nulliparous patients.
1. Obstet Gynecol 1996;88:993-1000
2. Am J Obstet Gynecol 1993;169:851-8
3. Am J Obstet Gynecol 1993;168:1881-5
A major statistical problem with
the study, which prevents the authors from
making the conclusions they have made, is the
failure to consider the interaction between
epidural anesthesia and oxytocin stimulation.
Many studies have shown that epidural anesthesia
increases the need for oxytocin stimulations
[refs]. A proper statistical procedure would
have been to use an interactive term for epidural
and oxytocin stimulation.
I would have started with a multivariate
analysis of variance which would have considered
the interaction between epidural anesthesia
and the other variables. The authors believe
(erroneously) that they are dealing with independent
variables. Clearly we all know that there is
an association between oxytocin induction and
epidurals (more difficult labors; more likely
to have an epidural), maternal age (younger
and older mothers are more likely to have epidurals),
oxytocin stimuation (women who have epidurals
are more likely to need oxytocin stimuation
because of the desultory effect of the epidural
on uterine contractions, private patients are
more likely to have epidurals.
The more sophisticated approach
to their paper would have been to use a technique
such as structural equations modeling (LISREL,
or related procedures) to test paths of effects.
For example, one can test the hypothesis that
epidurals affect the cesarean rate through
their effect on the need for uterine stimulation.
That could still be done with the authors'
data, and we plan to challenge them to an independent
data analysis (by our colleagues at the University
of Pittsburgh) using path analysis to test
Simply using logistic regression
in this context was inappropriately simplistic,
but done probably because it supported their
bias (epidurals are good!). I suspect the authors
are well-informed and have excellent biostatistical
consultation, and chose not to report these
other analyses that they probably did, because
these other analyses did not support their
I would draw your attention to
another part of the abstract. Is it reasonable
practice to do cesareans on 58% of women who
are older than 29 years and are being induced?
Are these numbers generalizable? I was shocked
to read this figure. In all my experience in
obstetrics, I can't imagine how you can perform
a cesarean on 58% of the women over age 29
whom you are inducing.
I would very much like to see
their criteria for cesarean. With such high
rates (45% in the epidural group and 58% in
the non-epidural group), I question how generalizable
these results are to good practice elsewhere.
Perhaps in an environment (consider how stressful
this environment must be) in which such high
cesarean rates occur, epidurals do decrease
the risk for cesarean if you are being induced,
but I can't believe that such high cesarean
rates constitute safe and prudent practice.
I would like to see their overall
complication rates, including post-partum infection
and the backache/headache complications of
epidurals. I suspect their morbidity is quite
2nd & 3rd additional studies:
Two other studies shed some light
on this debate. The first is Newton ER, Schroeder
BC, Knape KG, Bennett BL. Epidural analgesia
and uterine function. Obstet Gynecol 1995;
"Continuous epidural analgesia
with bupivacaine and fentanyl did not result
in a change in myometrial contractility in
the first hour after initiation of analgesia.
However, despite more oxytocin therapy, the
rate of cervical dilation was significantly
slower in the epidural group than in the nonepidural
group (1.9 versus 5.6 cm/hr, p < 0.001).
Operative deliveries were more common in patients
with epidural analgesia than in those without
it (12 of 62 versus 2 of 124, p < 0.0001).
After epidural analgesia, myometrial contractility
is maintained with oxytocin, but the ability
of the uterus to dilate the uterus is reduced
Also important, Albers LL, Anderson
D, Cragin L, Daniels SM, Hunter C, Sedler KD,
Teaf D. The relationship of ambulation in labor
to operative delivery. JNM 1997; 42(1):4-8.
"Women who ambulated for
a significant amount of time during labor (compared
with those who did not ambulate) had half the
rate of operative delivery (2.7% versus 5.5%)."
It's very hard to ambulate with either an epidural
Two others studies have been
widely quoted in the popular press. They included
a study by Dr. Steven Fogel, an anesthesiologist
at Washington University School of Medicine,
in St. Louis. Dr. Fogel looked at data on 7,000
patients delivering over a 28 month period
at his hospital. He compared cesarean rates
for first time mothers before the introduction
of an epidural on demand anesthesia service
to cesarean rates after the introduction of
the service, finding no change. What isn't
reported is how obstetrical practices changed
during this time interval, a very significant
factor. Such historical studies are notoriously
unreliable because policies change so rapidly
in obstetrical management. Without such information,
the study is meaningless.
The final study was done at Boston's
Beth Isreal-Deaconess Medical Center by anesthesiologist
Steven Pratt. This study reviewed the labor
and delivery records of more than 2300 women
who received ultra-low dose solutions of epidural
medications. The study showed that women who
needed additional pain relief beyond the low-doses
were more likely to have cesareans than women
who did not. Dr. Pratt argued that it was harder
labors that caused cesareans and not epidurals.
This study was so anecdotal as to be hardly
worth commenting upon. What Dr. Pratt failed
to note was that several others studies have
shown that patient satisfaction with low-dose
epidurals is very low and that more than half
of women have additional medication. Pratt's
study actually supports the point of view that
epidurals lead to increased cesareans, when
this information is taken into account.
What is amazing is the propagandizing
that went on in the press. The gold standard
in medicine consists of randomized, controlled
trials. These have been done and do generally
show increased cesarean rates. To try and argue
against these much better quality studies with
retrospective studies using historical controls
is poor science, but clearly good propaganda.
To conclude we list some of these studies and
Prospective Clinical Trials Investigating
the Association between Epidural Analgesia
and Cesarean Birth Rates by Randomizing Women
to a Narcotic versus an Epidural Group:
Reference and Parity Sample Size
Relative Risk of Cesarean
Birth with Epidural Analgesia (95% CI)
Parous** 637 3.8 (1.3-11.0)*
Combined*** 869 2.3 (1.3-4.0)*
All three prospective trials combined 1073
* Relative risk is statistically
significant at least at p < 0.05
** This represents the odds ratio for all women
in the study adjusted by multivariate logistic
*** The cesarean birth rate was significantly
greater (p = 0.002) in the epidural group (9%,
39/432) compared with the narcotic group (4%,
**** Comparison of the proportions by Mantel-Haenszel
yields a chi-squared of 18.1 and a p-value
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in labour and instrumental deliveries. Eur
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2. Thorp JA, Hu DH, Albin RM. The effect of
intrapartum epidural analgesia on nulliparous
labor: A randomized prospective trial. Am J
Obstet Gynecol 1993; 169:851-858.
3. Ramin SM, Gambling DR, Lucas MJ. Randomized
trial of epidural versus intravenous analgesia
during labor. Obstet Gynecol 1995; 86:783-789.
Eberle RL, Norris MC. Labour analgesia:
A risk-benefit analysis. Drug-Saf 1996; 14(4):239-251.
Kantor G. Obstetrical epidural anesthesia in
a rural Canadian hospital. Can J Anaesth 1992;
Thorp JA, Parisi VM, Boylan PC, Johnston DA.
The effect of continuous epidural analgesia
on cesarean section for dystocia in nulliparous
women [see comments]. American Journal of Obstetrics
& Gynecology 1989 Sep;161(3):670-5.
Adashek JA, Peaceman AM, Lopez-Zeno JA, Minogue
JP, Socol ML. Factors contributing to the increased
cesarean birth rate in older parturient women.
American Journal of Obstetrics & Gynecology
David J. Birnbach, M.D., Steven T. Fogel, M.D.,
Stephen D. Pratt, M.D.; New Data Debunks Belief
that Epidurals Cause Cesarean sections, San
Diego, Press Release, American Society of Anesthesiologists,
Sharma SK, Sidawi JE, Ramin SM, Lucas MJ, Leveno
KJ, Cunningham FG. Cesarean Delivery: A randomized
trial of epidural versus patient-controlled
meperidine analgesia during labor. Anesthesiology
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Center Experience: Journal of Nurse midwifery
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DAngelo R, Berkebile BL, Gerancher JC. Prospective
examination of epidural catheter insertion.
Anesthesiology 1996; 84(1) 88-93.
[LeBorgne, et al., 1991]
[Sghirlanzoni, et al., 1989]
[Sklar, et al., 1991]
[Parnass and Schmidt, 1990]
[Sghirlanzoni, et al., 1989 Oct]
[Whiting et al., 1990]
[Ackerman, et al., 1990]
[Gaudin and Lefant, 1990]
[Scott and Hibbard, 1990]
[Hachisuka, et al., 1991]
[Van Zundert and Scott, 1989]
[Gild and Crilley, 1990]
[Watanabe, et al., 1990]
[Elstein and Marx, 1990]
[Williams, et al., 1991]
[Xie and Liu, 1991]
[Klaus et al. 1993:47]
Epidural Ups Fever, C-Section Risk
SOURCE: American Journal of Public Health 1999;89:506-510.
Copyright 1999 Reuters Limited
April 6, 1999
NEW YORK (Reuters Health) -- Women who have a fever during labor are much more likely to have a cesarean section, and epidural anesthesia tends to increase the risk of fever, according to a study by Harvard researchers.
The findings suggest that fever may be one reason why women who have an epidural are more likely to have a cesarean rather than vaginal delivery, according to a report published in the American Journal of Public Health, the journal of the American Public Health Association.
A vaginal delivery is generally considered to be preferable to a cesarean section due to a quicker recovery time and a lower risk of complications.
In the study of 1,233 low-risk women undergoing childbirth for the first time at Brigham and Women's Hospital in Boston, Massachusetts, 301 women (24%) developed a fever over 99.5 degrees Fahrenheit.
About 25% of women who developed a fever underwent a cesarean section or an assisted vaginal delivery compared with 7% to 8% of women who did not have a fever.
Nine out of 10 women with elevated temperatures had received epidural anesthesia, but not all women receiving epidural anesthesia developed fever. Of the 736 women in the study who had an epidural, 37% developed an elevated temperature, compared with about 6% of women who did not receive an epidural, report Dr. Ellice Lieberman and colleagues from Brigham and Women's and Harvard Medical School.
While a fever can be associated with an infection, the researchers found that only a few cases of elevated temperature in the study were due to infection.
Previous studies have linked epidural use to a higher rate of cesarean and assisted vaginal deliveries, but the reason for the link was unclear.
"Our data suggest that the temperature elevation that is associated with epidural use may in part explain the higher rates of cesarean and assisted vaginal delivery," the authors conclude. "Given the widespread use of epidural analgesia, we believe that it is essential that further study be conducted to determine whether treatment or prevention of fever during labor represents a practical means of lowering rates of cesarean delivery and operative vaginal delivery."
Epidural pain relief is an increasingly popular choice for Australian women in the labour ward. Up to one-third of all birthing women have an epidural,(1) and it is especially common amongst women having their first babies.(2) For women giving birth by caesarean section, epidurals are certainly a great alternative to general anaesthetic, allowing women to see their baby being born, and to hold and breastfeed at an early stage: however their use as a part of a normal vaginal birth is more questionable(3)
There are several types of epidural used in Australian hospitals. In a conventional epidural, a dose of local anaesthetic is injected through the lower back into the epidural space, around the spinal cord. This numbs the nerves which bring sensation from the uterus and birth canal. Unfortunately, the local anaesthetic also numbs the nerves which control the pelvic muscles and legs, so with this type of epidural, a woman usually cannot move her legs and, unless the epidural has worn off, cannot push her baby out, in the second stage of labour.
More recent forms of epidurals use a lower dose of local anaesthetic, usually combined with an opiate, such as pethidine, morphine or fentanyl (sublimaze). With this low-dose or combination epidural, most women can move around with support; however the chance of a woman being able to give birth without forceps is still low(4). Another form of epidural, popular in the US, is the CSE, or combined spinal-epidural, where a one-off dose of opiate, with or without local anaesthetic, is injected into the spinal space, very close to the end of the spinal cord. This gives pain relief for around 2 hours, and if further pain relief is needed, it is given as an epidural. These forms of "walking epidural" may seem advantageous, but being attached to a CTG machine to monitor the baby, and hooked up to a drip which is also a requirement when an epidural is in place, can make walking impossible.
Many women have a good experience with epidurals. Sometimes the relief from pain can allow a woman to rest and relax sufficiently to go on and have a good birth experience. However deciding to use an epidural for pain relief can also lead to a "cascade of intervention", where an otherwise normal birth becomes highly medicalised, and a woman feels that she loses her control and autonomy. Often the decision to accept an epidural is made without an awareness of these, and other, significant risks to both mother and baby.
Although the drugs used in epidurals are injected around the spinal cord, substantial amounts enter the mother's blood stream, and pass through the placenta into the baby's circulation. Most of the side effects of epidurals are due to these "systemic", or whole-body effects.
One of the most commonly recognised side effects is a drop in blood pressure. Up to one woman in eight will have this side effect to some degree(5), and for this reason, extra fluids are usually given through a drip to prevent problems. A drop in the mother's blood pressure will affect how much of her blood is pumped to the placenta, and can lead to less oxygen being available to the baby.
An epidural will often slow a woman's labour, and she is three times more likely to be given an oxytocin drip to speed things up(6,7). The second stage of labour is particularly slowed, leading to a three times increased chance of forceps(8). Women having their first baby are particularly affected; choosing an epidural can reduce their chance of a normal delivery to less than 50%(9).
This slowing of labour is at least partly related to the effect of the epidural on a woman's pelvic floor muscles. These muscles guide the baby's head so that it enters the birth canal in the best position. When these muscles are not working, dystocia, or poor progress, may result, leading to the need for high forceps to turn the baby, or a caesarean section. Having an epidural doubles a woman's chance of having a caesarean section for dystocia(10).
When forceps are used, or if there is a concern that the second stage is too long, a woman may be given an episiotomy, where the perineum, or tissues between the vaginal entrance and anus, are cut to enlarge the outlet and hurry the birth. Stitches are needed and it may be painful to sit until the episiotomy has healed, in 2 to 4 weeks.
As well as numbing the uterus, an epidural will numb the bladder, and a woman may not be able to pass urine, in which case she will be catheterised. This involves a tube being passed up from the urethra to drain the bladder, which can feel uncomfortable or embarrassing.
Other side effects of epidurals vary a little depending on the particular drugs used. Pruritis, or generalized itching of the skin, is common when opiate drugs are given. It may be more or less intense and affects at least 1/4 of women(11,12): morphine or diamorphine are most likely to cause this. Morphine also causes oral herpes in 15% of women(13).
All opiate drugs can cause nausea and vomiting, although this is less likely with an epidural (around 30%)(14) than when these drugs are given into the muscle or bloodstream, where larger doses are needed. Up to 1/3 of women with an epidural will experience shivering(15), which is related to effects on the bodies heat-regulating system.
When an epidural has been in place for more than 5 hours, a woman's body temperature may begin to rise(16). This will lead to an increase in both her own and her baby's heart rate, which is detectable on the CTG monitor. Fetal tachycardia, or fast heart rate can be a sign of distress, and the elevated temperature can also be a sign of infection such as chorioamnionitis, which affects the uterus and baby. This can lead to such interventions as caesarean section for possible distress or infection, or, at the least, investigations of the baby after birth such as blood and spinal fluid samples, and several days of separation, observation, and possibly antibiotics, until the results are available(17).
Less common side effects for a woman having an epidural are; accidental puncture of the dura, or spinal cord coverings, which can cause a prolonged and sometimes severe headache (1 in 100)(18) ongoing numb patches, which usually clear after 3 months(1 in 550)(19); and weakness and loss of sensation in the areas affected by the epidural, (4-18 in 10,000) also usually resolving by 3 months(20).
More serious but rare side effects include permanent nerve damage; convulsions and heart and breathing difficulties (1 in 20,000)(21) and death attributable to epidural. (1 in 200,000)(22) When opiates are used, a woman may experience difficulty in breathing which comes on 6 to 12 hours later.(23)
There is a noticeable lack of research and information about the effects of epidurals on babies.(24) Drugs used in epidurals can reach levels at least as high as those in the mother(25), and because of the baby's immature liver, these drugs take a long time- sometimes days- to be cleared from the baby's body.(26) Although findings are not consistent, possible problems, such as rapid breathing in the first few hours(27) and vulnerability to low blood sugar(28) suggest that these drugs have measurable effects on the newborn baby.
As well as these effects, babies can suffer from the interventions associated with epidural use; for example babies born by caesarean section have a higher risk of breathing difficulties.(29) When monitoring of the heart rate by CTG is difficult, babies may have a small electrode screwed into their scalp, which may not only be unpleasant, but occasionally can lead to infection.
There are also suggestions that babies born after epidurals may have difficulties with breastfeeding(30,31) which may be a drug effect, or may relate to more subtle changes. Studies suggest that epidurals interfere with the release of oxytocin(32) which, as well as causing the let-down effect in breastfeeding, encourages bonding between a mother and her young(33).
Epidural research, much of it conducted by the anaesthetists who administer epidurals, has unfortunately focussed more on the pro's and con's of different drug combinations than on possible serious side-effects(34). There have been, for example, no rigorous studies showing whether epidurals affect the successful establishment of breastfeeding(35).
Several studies have found subtle but definite changes in the behaviour of newborn babies after epidural(36,37,38) with one study showing that behavioural abnormalities persisted for at least six weeks(39). Other studies have shown that, after an epidural, mothers spent less time with their newborn babies(40), and described their babies at one month as more difficult to care for.(41)
While an epidural is certainly the most effective form of pain relief available, it is worth considering that ultimate satisfaction with the experience of giving birth may not be related to lack of pain. In fact, a UK survey which asked about satisfaction a year after the birth found that despite having the lowest self-rating for pain in labour (29 points out of 100), women who had given birth with an epidural were the most likely to be dissatisfied with their experience a year later.(42)
Some of this dissatisfaction was linked to long labours and forceps births, both of which may be a consequence of having an epidural. Women who had no pain relief reported the most pain (70 points out of 100) but had high rates of satisfaction.
Pain in childbirth is real, but epidural pain relief may not be the best solution. Talk about other options with your care-givers and friends. With good support, and the use of movement, breathing and sound, most women can give themselves, and their babies, the gift of a birth without drugs.
1) Perinatal Statistics, Queensland 1996. Queensland Health 1998. At the present time, national figures for epidural use are not collected.
2) Dr Steve Chester, Head of Anaesthetics Dept, Royal Women's Hospital, Melbourne. Around 45% of primiparous women at RWH have an epidural. Personal Communication
3) World Health Organisation. Care in Normal birth: A Practical Guide..P 16. WHO 1996
4) Russell R, Reynolds F. Epidural infusion of low-dose bupivicaine and opioid in labour. Does reducing the motor block increase the spontaneous delivery rate? Anaesthesia 1996; 51(5): 266-273
5) Webb RJ, Kantor GS. Obstetrical epidural anaesthesia in a rural Canadian hospital. Can J Anaesth 1991; 39:390-393
6) Ramin SM, Gambling DR, Lucas MJ et al. Randomized trial of epidural versus intravenous analgesia during labor. Obstet Gynecol 1995; 86(5): 783-789
7) Howell CJ. Epidural vs non-epidural analgesia in labour. [Revised 6 May 1994] In: Keirse MJNG, Renfrew MJ, Neilson JP, Crowther C. (eds) Pregnancy and Childbirth Module. In: The Cochrane Pregnancy and Childbirth Database.
(database on disc and CD-ROM ) The Cochrane Collaboration; Issue 2, Oxford: Update Software 1995 (Available from BMJ publishing group, London)
8) Thorp JA, Hu DH, Albin RM, et al. The effect of intrapartum epidural analgesia on nulliparous labor; a randomized, controlled, prospective trial. Am J Obstet Gynecol 1993; 169(4): 851-858
9) Paterson Catherine, Banfield Philip. Epidural analgesia and maternal satisfaction. BMJ 1991 v302: 1079
10) Thorp JA, Meyer BA, Cohen GR et al. Epidural analgesia in labor and cesarean section for dystocia. Obstet Gynecol Surv 1994; 49(5): 362-369
11) Lirzin JD, Jacquintot P, Dailland P, et al. Controlled trial of extradural bupivicaine with fentanyl, morphine or placebo for pain relief in labour. Br J Anaesth 1989; 62: 641-644
12) Caldwell LE, Rosen MA, Shnider SM. Subarachnoid morphine and fentanyl for labor analgesia. Efficacy and adverse effects. Reg Anesth 1994;19:2-8
13) John Paull, Faculty of Anaesthetists, Melbourne. Quoted in: "The perfect epidural for labour is proving elusive" New Zealand Doctor. 21 Oct 1991
14) as above
15) Buggy D, Gardiner J. The space blanket and shivering during extradural analgesia in labour. Acta-Anaesthesiol-Scand 1995; 39(4): 551-553
16) Camann WR, Hortvet LA, Hughes N, et al. Maternal temperature regulation during extradural analgesia for labour. Br J Anaesth 1991;67:565-568.
17) Kennell J, Klaus M, McGrath S, et al. Continuous emotional support during labor in a US hospital. JAMA 1991;265:2197-220
18) Stride PC, Cooper GM. Dural taps revisited: a 20 year survey from Birmingham Maternity Hospital. Anaesthesia 1993; 48(3):247-255
19) Epidurals for pain relief in labour: Informed choice leaflet for women. MIDIRS and the NHS centre for Reviews and dissemination 1997.
20) Epidural pain relief during labour; Informed choice for professionals. MIDIRS and the NHS centre for Reviews and dissemination 1997.
21) see 13
22) see 13
23) Rawal N, Arner S et al Ventilatory effects of extradural diamorphine.Br J Anaesthesia 1982;54:239
24) Howell CJ, Chalmers I. A review of prospectively controlled comparisons of epidural with non-epidural forms of pain relief during labour. Int J Obstet Anaesth 1992;1:93-110
25) Fernando R, Bonello E et al. Placental and maternal plasma concentrations of fentanyl and bupivicaine after ambulatory combined spinal epidural (CSE) analgesia during labour. Int J Obstet Anaesth 1995;4:178-179
26) Caldwell J, Wakile LA, Notarianni LJ et al. Maternal and neonatal disposition of pethidine in child birth- a study using quantitative gas chromatography-mass spectrometry. Lif Sci 1978;22:589-96
27) Bratteby LE, Andersson L, Swanstrom S. Effect of obstetrical regional analgesia on the change in respiratory frequency in the newborn. Br J Anaesth 1979; 51:41S-45S
28) Swanstrom S, Bratteby LE. Metabolic effects of obstetric regional analgesia and of asphyxia in the newborn infant during the first two hours after birth I. Arterial blood glucose concentrations. Acta Paediatr Scand 1981; 70:791
29) Enkin M, Keirse M, Renfrew M, Neilson J. A Guide to Effective Care in Pregnancy and Childbirth. P 287 Oxford University Press 1995
30) Smith A. Pilot study investigating the effect of pethidine epidurals on breastfeeding. Breastfeeding Review, Nursing Mothers Association of Australia. V5 no1 May 1997.
31) Walker M. Do labor medications affect breastfeeding? J Human Lactation 1997;13(2) 131-137
32) Goodfellow CF, Hull MGR, Swaab DF et al. Oxytocin deficiency at delivery with epidural analgesia. Br J Obstet Gynaecol 1983; 90:214-219
33) Insel TR, Shapiro LE. Oxytocin receptors and maternal behavior. In Oxytocin in Maternal Sexual and Social Behaviors. Annals of the New York Academy of Sciences, 1992 Vol 652. Ed CA Pedersen, JD Caldwell, GF Jirikowski
and TR Insel pp 122-141 New York, New York Academy of Science
34) Howell CJ, Chalmers I A review of prospectively controlled comparisons of epidural with non-epidural forms of pain relief during labour. Int J Obstet Anaesth 1992 1: 93-110
35) See 31
36) Scanlon JW, Brown WU, Weiss JB Alper MD. Neurobehavioral responses of newborn infants after maternal epidural anesthesia. Anesthesiology, 1974; 40: 121-128
37) Morikawa S, Ishikawa I, Kamatsuki H, et al. Neurobehavior and mental development of newborn infants delivered under epidural analgesia with bupivicaine. Nippon Sanka 1990; 42: 1495-1502
38) Lester BM, Heidelise A, Brazelton TB. Regional obstetric anesthesia and newborn behavior: a synthesis toward synergistic effects.Child Dev 1982; 53;687-692
39) Rosenblatt DB, Belsey EM, Lieberman BA et al. The influence of maternal analgesia on neonatal behaviour II epidural bupivicaine. Br J Obstet Gynecol 1981 24;649-670
40) Seposki C, Lester B, Ostenheimer GW, Brazelton, TB. The effects of maternal epidural anesthesia on neonatal behavior during the first month. Dev Med Child Neurol 1992:34;1072-1080
41) Murray AD, Dolby RM, Nation RL, Thomas DB.Effects of epidural anesthesia on newborns and their mothers. Child Dev 1981; 82:71-82
42) Morgan BM, Bulpitt CJ, Clifton P, Lewis PJ. Analgesia and satisfaction in childbirth (the Queen Charlotte's 1000 mother survey) Lancet 1982; 2 (Oct 9) 808-810