Epidural during Labor for Pain Management

by | Jun 26, 2024


Today’s video is all about the benefits and risks of using an epidural during labor for pain management. As a reminder, here is our disclaimer and terms of use.

You’ll learn:

  • How often epidurals during labor are used, and the difference between epidurals, spinals, and combined spinal epidurals (CSEs)
  • The benefits of epidurals, spinals, and CSEs
  • The potential risks and side effects of epidurals, spinals, and CSEs
  • The implications of the Kearns et al. (2024) study from Scotland about the impact of epidurals on severe maternal complications (audio only; not in YouTube video)
  • What the professional guidelines say about epidurals during labor
  • Content note: Discussion of needles, medical interventions, and severe maternal complications of labor

Watch, Read or Listen:

To read, please view the transcript below. To listen, subscribe to our podcast:  iTunes  |  Spotify  | YouTube

·      Check out the EBB Pocket Guide to Comfort Measures here.
·      Find an EBB Childbirth Class near you here.
EBB Episodes about Epidural Use:
EBB Birth Stories featuring Epidural Use:
  • American Association of Nurse Anesthesiology (AANA). (2017, Updated 2022). “Analgesia and Anesthesia for the Obstetric Patient: Practice Guidelines.” Click here.
  • American College of Obstetricians and Gynecologists. (2019). “Obstetric analgesia and anesthesia. Practice Bulletin No. 2019.” Obstetrics & Gynecology. Click here.
  • American Society of Anesthesiologists (ASA). (2016). “Practice Guidelines for Obstetric Anesthesia: An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology.” Anesthesiology 124(2), 270-300. Click here.
  • Anim-Somuah, A., Smyth, R.M.D., Cyna, A.M., Cuthbert, A. (2018). “Epidural versus non-epidural or no analgesia for pain management in labour.” Cochrane Database Syst Rev (5) CD000331. Click here.
  • Butwick, A.J., Bentley, J., Wong, C.A., et al., (2018). “United States State-Level Variation in the Use of Neuraxial Anesthesia During Labor for Pregnant Women.” JAMA Network Open, 1(8), e186567. Click here.
  • Callahan, E.C., Lee, W., Aleshi, P., et al., (2023). “Modern labor epidural analgesia: implications for labor outcomes and maternal-fetal health.” American Journal of Obstetrics and Gynecology, 228(5), S1260-S1269. Click here.
  • Chaillet, N., Belaid, L., Crochetière, C., et al. (2014). “Nonpharmacologic approaches for pain management during labor compared with usual care: A meta-analysis.” Birth, 41(2), 122-137. Click here.
  • D’Angelo, R., Smiley, R. M., Riley, E. T., et al. (2014). “Serious complications related to obstetric anesthesia: the serious complication repository project of the Society for Obstetric Anesthesia and Perinatology.” Anesthesiology, 120(6), 1505-1512. Click here.
  • Guglielminotti, J., Landau, R., Daw, J., et al. (2022). “Use of Labor Neuraxial Analgesia for Vaginal Delivery and Severe Maternal Morbidity.” JAMA Network Open, 5(2), e220137. Click here.
  • Hale, S., Hill, C.M., Hermann, M., et al. (2020). “Analgesia and Anesthesia in the Intrapartum Period”. Journal of Obstetric, Gynecologic & Neonatal Nursing, 49(2), e1-e60. Click here.
  • Hawkins, J. L., Chang, J., Palmer, S. K., et al. (2011). “Anesthesia-related maternal mortality in the United States: 1979-2002.” Obstet Gynecol, 117(1), 69-74. Click here.
  • Hegvik, T., Klungsøyr, K., Kuja-Halkola, R., (2023). “Labor epidural analgesia and subsequent risk of offspring autism spectrum disorder and attention-deficit/hyperactivity disorder: a cross-national cohort study of 4.5 million individuals and their siblings.” American Journal of Obstetrics and Gynecology (AJOG), 228(2), 233.e1-233.e12. Click here.
  • Hussain, N., Lagnese, C.M., Hayes, B., et al., (2020). “Comparative analgesic efficacy and safety of intermittent local anaesthetic epidural bolus for labour: a systematic review and meta-analysis.” British Journal of Anaesthesia, 125(4), 560-579. Click here.
  • Jansen, S., Lopriore, E., Naaktgeboren, C., et al., (2020). “Epidural-Related Fever and Maternal and Neonatal Morbidity: A Systematic Review and Meta-Analysis.” Neonatology, 117(3), 259-270. Click here.
  • Juang, J., Gabriel, R.A., Dutton, R.P., et al. (2017). “Choice of Anesthesia for Cesarean Delivery: An Analysis of the National Anesthesia Clinical Outcomes Registry.” Anesthesia and Analgesia 124(6), 1914-1917. Click here.
  • Kearns, R.J., Lucas, D.N. (2023). “Neuraxial analgesia in labour and the foetus.” Best Practice & Research Clinical Anaesthesiology, 37(1), 73-86. Click here.
  • Knight M, Bunch K, Tuffnell D, et al. (Eds.) on behalf of MBRRACE-UK. (2020). “Saving Lives, Improving Mothers’ Care – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2016-18.” Oxford: National Perinatal Epidemiology Unit, University of Oxford. Click here.
  • Morton, S., Kua, J., Mullington, C.J. (2021). “Epidural analgesia, intrapartum hyperthermia, and neonatal brain injury: a systematic review and meta-analysis.” British Journal of Anaesthesia, 126(2), 500-515. Click here.
  • NHS. (February 2023). “Side effects: Epidural.” Accessed online on January 12, 2024. Available here.
  • NHS. (March 2023). “Pain relief in labour.” Accessed online on January 12, 2024. Available here.
  • NHS (December 2020). “Deliveries in 2019-20.” Accessed online on January 14, 2024. Available here.
  • Nucleus Medical Media (2009). “Video: Epidural & spinal anesthesia.” Accessed online on October 2, 2017. Available here.
  • Orbach-Zinger, S., Heesen, M., Grigoriadis, S. (2021). “A systematic review of the association between postpartum depression and neuraxial labor analgesia.” International Journal of Obstetric Anesthesia, 45, 142-149. Click here.
  • Qiu, C., Lin, J.C., Shi, J.M., et al. (2020). “Association Between Epidural Analgesia During Labor and Risk of Autism Spectrum Disorders in Offspring.” JAMA Pediatrics, 174(12), 1168-1175. Click here.
  • Ren, T., Zhang, J., Yu, Y., et al. (2022). “Association of labour epidural analgesia with neurodevelopmental disorders in offspring: a Danish population-based cohort study.” British Journal of Anaesthesia, 128(3), 513-521. Click here.
  • Roofthooft, E., Rawal, N., Van de Velde, M. (2023). “Current status of the combined spinal-epidural technique in obstetrics and surgery.” Best Practice & Research. Clinical Anaesthesiology, 37(2), 189-198. Click here.
  • Seijmonsbergen-Schermers, A., van den Akker, T., Rydahl, E., et al. (2020). “Variations in use of childbirth interventions in 13 high-income countries: A multinational cross-sectional study.” PLoS Med, 17(5), e1003103. Click here.
  • Simmons, S.W., Taghizadeh, N., Dennis, A.T., et al. (2012). “Combined spinal-epidural versus epidural analgesia in labour.” Cochrane Database of Systematic Reviews (10), CD003401. Click here.
  • Turner, J., Flatley, C., Kumar, S. (2020). “Epidural use in labour is not associated with an increased risk of maternal or neonatal morbidity when the second stage is prolonged”. Australian and New Zealand Journal of Obstetrics and Gynaecology, 60(3), 336-343. Click here.
  • Xu, J., Zhou, J., Xiao, H., et al. (2019). “A Systematic Review and Meta-Analysis Comparing Programmed Intermittent Bolus and Continuous Infusion as the Background Infusion for Parturient-Controlled Epidural Analgesia.” Scientific Reports, 9(1), 2583. Click here.
  • Yin, H., Ton, X., Huang, H. (2022). “Dural puncture epidural versus conventional epidural analgesia for labor: a systematic review and meta-analysis of randomized controlled studies.” Journal of Anesthesia, 36(3), 413-427. Click here.
View the transcript

Dr. Rebecca Dekker –

Hey everyone, on today’s podcast, we’re going to share an overview of the evidence on epidurals for pain management during labor. Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Dekker, and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details. Hi everyone and welcome to today’s episode of the Evidence Based Birth® Podcast. Before we get started, I wanted to let you know that we are gearing up the second week of July to host a free 30-day trial of the EBB Pro Membership. So, if that is something you’ve been interested in getting more involved here at EBB, make sure you go to evidencebasedbirth.com and join our free newsletter so that you can be notified when that trial period is open.

And now I’m so excited to bring some brand-new evidence-based information to you all about epidurals. Now, today’s podcast episode, EBB 317, is replacing EBB 9, which is one of the first 10 episodes on our podcast produced back in the year 2018. Now, if you prefer to learn by video, make sure you visit the Evidence Based Birth® YouTube channel, where you’ll find a new high-definition video all about the evidence on epidurals. You can also find all the scientific references for this podcast episode on our website at ebbirth.com/317. Our last podcast on this topic was released six years ago, so we’ve got a lot of new research to discuss. We’re going to be talking all about what are epidurals? What does the evidence show about the effectiveness of epidurals? What are the benefits, risks, and alternatives? What do the professional guidelines say? And what is the bottom line? A lot of this research was uncovered for us by Morgan Cayama Richardson, one of our EBB Research Fellows. So, a big thank you to Morgan for her help in compiling this research for you today. Quick note: About 20 minutes into this podcast, I have a late addition to the information I share, all about a new study from Scotland, that is getting a lot of news coverage, about epidurals. So we’ll go into that study after the benefits, risks, and alternatives. Are you ready to get started? All right, let’s go.

So first, let’s talk all about epidurals. And we’re also going to be talking about spinals and combined spinal epidurals. Epidurals, spinals, and combined spinal epidurals are pharmacologic or medication methods used to manage pain during labor. They’re often referred to as regional analgesics, and this is because they relieve pain in one region of the body, and analgesia is the medical term for pain relief. They’re also sometimes called neuraxial analgesia or an epidural block or a spinal block. More than 70% of people giving birth in the US use some type of regional analgesia. This is a pretty high percentage compared to most other high-resourced countries. For example, in England, epidural use is only around 20 to 30% of all births. In the Netherlands, it’s about 30%. Sweden, 45% and Ireland, 65%. And epidural rates in hospitals can vary depending on the culture or practice patterns at that hospital.

So first, let’s talk about epidurals. An epidural is when a catheter is placed in your lower back in an area right beneath where the spinal cord ends. An epidural can block feeling in the lower part of your body, also causing some numbness. But you remain fully awake and alert. And whether or not you can still move your legs depends on the dose of medication you’re given and your body’s reaction to the epidural. So how is an epidural given? Well, after getting your informed consent, a trained healthcare provider inserts a small needle into your back. And over on top of that needle is a small plastic tube, also known as the epidural catheter. The needle is used to guide the small plastic catheter into the epidural space in your back. Again, it’s located right below the bottom of your spinal cord. After they get the catheter in your back, they retract or remove the needle. So, it’s just the thin plastic catheter remaining in your epidural space. Medicine can then be given through that small tube to help with pain during labor and more medication or higher doses can be given to numb you up even more if you end up needing a caesarean, forceps or vacuum delivery. If everything goes smoothly, an epidural takes about 10 minutes to set up and it can take about 10 to 20 minutes after that for the medication to start taking effect.

An epidural does not always work well at first. And sometimes your medications may need to be adjusted so that you get the pain management during labor that you’re looking for. Epidural medications typically consist of a local anesthetic often mixed with an opioid. The use of both the local anesthetic and the opioid allows for smaller doses of both drugs to be given. The two anesthetics that are commonly used in the United States are bupivacaine and ropivacaine, and the two opioids that are commonly used in the U.S are fentanyl or sufentanil. Sometimes epinephrine or sodium bicarbonate are also added to the Epidural medication mixture to enhance the medicine’s onset, duration, and intensity. Epidural medication can be given in a few different ways depending on options and practice patterns at your hospital. A continuous epidural infusion is where a continuous flow of medication is slowly pumped through the catheter in your back. A bolus is the medical term for getting an extra dose of medicine or fluid, so it might be instead of a continuous infusion you just receive intermittent boluses of medication.

There are also situations where you might be given a continuous infusion plus boluses, or there are also patient-controlled boluses called patient-controlled analgesia where you are given a button attached electronically to the pump so you can push the button if you need an extra dose of medication to help manage pain. However, these types of PCA pumps are programmed to only allow a certain number of doses within a certain time span to prevent you from receiving too much medication. This is going to be blocked so it can’t be tampered with. One systematic review and meta-analysis that we found where researchers are looking at lots of different studies found that intermittent boluses with patient-controlled analgesia led to better outcomes compared to continuous infusions with patient-controlled analgesia. And some of the better outcomes that they saw included lower use of forceps and vacuum deliveries, shorter labors, and less use of the medications, while still providing high birth satisfaction. A spinal block is somewhat like an epidural. It’s given as an injection in your lower back, but it’s given with a much smaller, thinner needle and with a much smaller dose of medication. The spinal medications are injected into a sac of spinal fluid that’s right below the spinal cord in your back, and it will cause a loss of feeling or sensation in your lower body.

A spinal block is usually only given once during labor, and it provides immediate pain relief so it starts working right away. But it’s only good for about one to two hours. Because of this, it’s primarily given to you if your delivery is expected within an hour or so, or if they are planning on a Cesarean and they want to block all feeling during a Cesarean. Then you can also combine an epidural and spinal into one intervention, and that is called the combined spinal epidural block, sometimes abbreviated CSE. With this, you get the benefits of both methods. You get the immediate pain relief of a spinal, and you get the continuous pain management of an epidural. Another benefit of the CSE is that lower doses of medications can sometimes be used. And so this is what people refer to when they talk about a walking epidural, because the theory is that if you have the lowest doses of the combined spinal epidural, you may be able to retain more mobility. However, there was a Cochrane review a while ago where they combined a whole bunch of studies on CSEs and traditional epidurals, and they found no difference in how mobile you are with an epidural versus a CSE. So it’s really debatable whether we can call it a walking epidural.

Studies have shown an increased risk in fetal bradycardia, which is when the baby’s heart rate slows, or in fetal heart rate abnormalities with the CSE compared to a traditional epidural, but this has not been shown to impact the Cesarean rate. You’re also more likely to experience itchy skin with a CSE versus with a traditional epidural. Another method that’s new to this podcast that we have not covered before is something called the dural puncture epidural, or DPE. This is a newer technique that we’re starting to hear more about. It is a modification of the CSE and the traditional epidural method. We found one systematic review on this subject comparing the risks and benefits of the DPE to the traditional epidural. And they did find that pain scores were lower among the DPE group. They didn’t need as many doses of medication and they had less nausea and vomiting. However, because this is a newer anesthesia technique and much of the research comparing the DPE to other epidural methods has not shown an overwhelming benefit. It’s still not widely used. And so here at EBB, we’ll be watching the research coming out on this over the next few years.

Now, going back to epidurals, spinals, and CSEs. Let’s talk about their benefits during labor. Now these three methods all carry pretty much the similar benefits and similar side effects. And so as I’m talking about benefits and side effects, they apply to all of these methods, unless I single out a specific method. So the main benefit of regional analgesia is that it is considered the most effective form of pain management during labor. In 2018, Aneem Suma et al published a Cochrane review of 40 studies that included more than 11,000 participants who were receiving any form of regional analgesia during labor, and they compared them with people who were receiving other forms of pain medication or no pain medication at all. Now most of the studies compared epidurals with injectable opioids. And if you haven’t listened to it yet, we did cover the evidence on injectable opioids in EBB 312. The researchers found that participants who had an epidural during labor reported less pain, more satisfaction with their pain relief, and were 90% less likely to need additional pain medications. They were also much less likely to have respiratory depression, meaning their breathing slowed. They were much less likely to need oxygen. And they were less likely to have nausea and vomiting compared to those who received injectable opioids through an IV or IM injection. Their babies were less likely to have low cord pH after birth. Which is good compared to those receiving opioids. And they were much less likely to need medication to reverse the effects of opioids.

This makes sense because the pain medication in the epidural, a small amounts of it can get into the baby in utero. But when you’re giving a medication through someone’s vein, it’s going straight into your blood and being pumped around. It makes sense that the injectable opioids would have more side effects for babies because you have that more direct route for the medication to get into the babies body. So epidural type pain medications were considered to be safer for babies compared to injectable opioids. Having an epidural did not impact the rate of Cesarean. It did not impact the risk of severe tears in the perineal area. It had no impact on postpartum depression, backache, headache, itching, shivering, or drowsiness compared to the injectable opioids. Another benefit of epidurals that we have not seen measured in studies, but we hear a lot from our childbirth class students, is that if someone is really tired or exhausted from a long labor or induction, epidurals can help you rest and relax and get some much needed sleep. Another side benefit is that having an epidural in place during labor could be beneficial if you needed an urgent Cesarean. If a Cesarean became necessary and you already have a functioning epidural in place, the existing epidural can be used for the surgery for anesthesia by simply adding a higher concentration of medication.

According to the American Congress of Obstetricians and Gynecologists, converting an epidural to a higher concentration takes only about 10 minutes and it can be done while you’re preparing to transport someone to the operating room. On the other hand, if you were laboring without an epidural and an emergency or urgent Cesarean was necessary, then you would need either a spinal or general anesthesia before the surgery. In expert hands, spinal anesthesia takes only about 8 minutes to reach the right level of block for a surgery. However, it’s possible there could be problems placing a spinal block during an urgent Cesarean, which could cost time. So in that case, it can be an advantage to already have an existing epidural. General anesthesia is used with only about 6% of Cesareans in the US and it is the quickest method to use for an emergency surgery, but it does increase the risk of anesthesia complications. One more benefit about epidurals has to do with avoiding suffering. There is actually research evidence that severe pain when you’re suffering can lead to a higher maternal stress response, along with decreased blood flow and therefore decreased oxygen to the baby.

So researchers have theorized that effective pain management can reduce your stress reaction and improve blood supply to the baby. So, so far, those are the benefits that we know about with epidurals. But what about the side effects or risks of epidurals? The Cochrane review that I mentioned earlier found that epidurals are very effective, but they also found a lot of side effects. Compared to injectable opioids or no medication pain relief at all, those who had an epidural had 11 times the risk of experiencing low blood pressure, also called hypotension. The risk of fever was three times. There was also an increased risk of having issues passing urine during labor, which requires a catheter to be inserted to allow urine to drain. And the people at epidurals were much more likely to have something called heavy motor block, where your legs are heavy and you have extreme difficulty moving the lower parts of your body while the epidural is in effect. They also found that epidurals can increase the length of labor by about 32 minutes in the first stage and 15 minutes in the second stage. And we’ll talk more about the increased length of labor and pushing in another podcast.

Now, in the first stage, in the past, research has shown that people with epidurals are more likely to need additional assistance with pushing the baby out, either through a forceps or vacuum-assisted delivery. But when the Cochrane Reviewers only included more recent studies from 2005 onward, the increased risk of needing forceps or vacuum disappeared. This is likely because of more modern techniques of administering epidurals, like having PCA and lower doses has reduced the side effects that it’s not statistically significant in the studies anymore. Sometimes we get questions about do epidurals increase the risk of postpartum depression? And there are some studies on this. We found a systematic review on this topic published in 2021 that included 11 observational studies with about 5,700 birthing people. This was published by Orbach-Singer et al. Nine of the 11 studies found no significant differences between epidural use and postpartum depression, while two of the 11 studies found significantly lower chances for postpartum depression among people who had epidurals during labor. There were some limitations. These were all observational studies. There was a lot of variation in the study designs used. And people who choose to have an epidural may differ from those who don’t, which could impact the risk of PPD.

Looking at other risks and side effects from regional analgesia during labor include itchy skin, feeling sick, having inadequate pain relief, having a headache or spinal headache, your breathing slowing down, you’re feeling drowsy. Temporary nerve damage felt as tingles or pins and needles down one leg or a small numb area. This type of nerve damage is temporary and usually resolves within a few days or weeks, but in some cases can take months. And then looking at very rare complications such as seizures, severe breathing difficulties, severe nerve damage or death. These are extremely rare. In fact, death from epidurals is so rare that one study, during a 10-year period across the United States found zero reported deaths from epidurals during labor. One more thing to consider with epidurals is how an epidural during labor can medicalize your birth. So you can think of an epidural as like a bundle of interventions. It’s not just the epidural. There are things that automatically go along with an epidural, such as continuous oxygen monitoring with a probe on your finger, a cuff that will be in your arm to measure your blood pressure frequently, additional IV fluids through an IV catheter. You may need pitocin or oxytocin to help augment or speed up your labor if it slows down from the epidural. There’s also a chance you’d need to have a catheter in your bladder.

Also, most people will be on a continuous fetal monitor with an epidural, and so you’ll have several belts strapped around your abdomen. Then in some cases, if you have a heavy motor block, you may have a higher risk of needing a vacuum delivery at the end of the second stage to help get your baby out. In terms of the effects on the baby. We’ll cover the impact of epidurals on lactation in a separate podcast episode, but opioids can cross the placenta. Again, you receive smaller doses with an epidural than you would with injectable opioids, but there still is a possibility that the baby could be affected. They could have a lower Apgar score and lower muscle tone. However, again, these side effects are much less likely with regional analgesia than they would be with injectable opioids. So we’ve talked about the effectiveness of epidurals as well as the benefits and the risks, but are there any alternatives? When it comes to planning a birth, it’s important to have alternative comfort measures because number one, there’s no guarantee you will be able to get an epidural at the time you want it. And sometimes they don’t work or maybe they only work partially or they’re delayed in their effectiveness. So one of the beautiful things about building a toolkit of comfort measures is that you have a variety of options to choose from. Before you get an epidural instead of an epidural or after you get an epidural. We talk a lot about comfort measures in our EBB Childbirth Class and in our Evidence Based Birth® Pocket Guide to Comfort Measures and alternatives include other medications as well.

So there’s medications such as injectable opioids and nitrous oxide. And then there are so many non-medication forms of comfort management, such as getting in a tub of warm water, taking a shower, having a doula with you, using a birth ball or using yoga positions, deep breathing, meditation, acupressure, acupuncture, massage, and so many more. For example, let’s say you’re planning on getting an epidural. But what if you’re uncomfortable or in pain during a car ride to the hospital? What comfort measures could you use during the car ride to manage your comfort level? Maybe it’s music or self-hypnosis or a TENS unit that you bring along. If you’re having a hospital birth. What comfort measures would you like to combine with an epidural to help lower your anxiety and improve your overall comfort? For example, what positions can you use if you have an epidural? What tools can you use such as peanut balls, meditation, aromatherapy? All of these things can help improve your overall comfort. So this is where at EBB we love when we hear people taking comprehensive childbirth classes or hiring a doula so that they can have access to the full range of comfort tools, whether or not they intend on having an epidural. 

So before we move onto the next section of this podcast, I want to insert a new section all about a new study that had come out after I initially recorded this episode. So I want to take a few minutes to talk about this study that just came out of Scotland, since I know many of you are wondering about it, and we have been asked about it a lot.

So some of you may have seen the press coverage of this study. One news article that I saw had the headline, “Epidurals during labor significantly decrease complications, according to new study.” And multiple news outlets in the United States and United Kingdom had a headline that reads “Epidurals during labor drop risk of severe complications by 35%.” I imagine that this study might impact how we see some doctors or midwives talking with their clients about epidurals in the future. Here at EBB, we specialize in taking research evidence and making it accessible and understandable. Fortunately, this particular research study is freely available to the public, at this moment at least. But unfortunately, it’s rather hard to understand. So I’m going to break it down for you.

This study was published by Kearns et al. and released by the British Medical Journal in April 2024. This was a population-based study of all women who labored in National Health System hospitals in Scotland between 2007 and 2019. They excluded patients who had important missing data, and they also excluded women who planned Cesareans because they were not going to experience labor. They were able to link six high-quality databases that tracked all obstetric and newborn outcomes.

The study ended up including about 541,000 women in labor between 24- and 42-weeks’ gestation who gave birth vaginally or through unplanned Cesareans in obstetric units. So they did not include home or in midwifery led birth centers in this study. The primary health outcome the researchers were interested in was something called severe maternal morbidity, also called severe maternal complications. They used a definition from the United States’ CDC of severe maternal morbidity that includes 21 conditions such as eclampsia, heart attack, hysterectomy (aka removal of the uterus), sepsis that includes an admission to critical care, postpartum hemorrhage that includes a critical care admission, acute respiratory distress, severe complications from anesthesia, among others. You can just google CDC severe maternal morbidity to get that full list of the 21 conditions.  So they measured to see if these adverse events happened anytime from the date of delivery to 42 days postpartum. One of the reasons they did this study is because the rate of severe maternal morbidity has been increasing in Scotland since 2009, and now makes up about 1.7% of all deliveries. So the researchers wanted to see if there is any association between epidurals and rates of severe maternal morbidities. They also wanted to examine pre-term births to see if epidurals have any kind of additional benefit on health outcomes in those situations.

So to give you some more background info, in Scotland, the typical epidural or conventional epidural is what is usually used, so combined spinal epidurals are rare and only make up 1% of all regional analgesia techniques used during labor.

Also, rates of epidurals are low in Scotland, and in this study only 22% of patients had an epidural in labor. I think this is partly why this study was done, to try and add more documented benefits of epidurals, because sometimes women are coerced into NOT having epidurals. In fact, if you do a Google search on epidurals in the United Kingdom, you’ll find articles from advocates about how difficult it can be to get an epidural sometimes, in labor. In particular, the researchers mention that those from ethnic minority groups and those who live in areas of socioeconomic deprivation are less likely to have access to epidurals or to be given epidurals. They also have higher rates of severe maternal morbidities in those populations. So, that just gives you an important piece of background info and insight into why this study was performed in the first place.

So once they collected the data, for the analysis, they split the population into two groups—those that had a conventional epidural, and those who did not have an epidural. They then compared those two groups, looking at all their characteristics, and then they looked at their primary outcome of severe maternal morbidity, they did adjust for some underlying pre-existing risk factors. And they also did additional analyses where they looked specifically at preterm birth. And they did additional data analyses with data from people who they considered to have a medical reason for having an epidural during labor—they consider people who have a medical indication for an epidural to include those with heart or lung disease, pre-eclampsia, having had a previous Cesarean, breech presentation, multiples, and a BMI 40 or higher.

So as I mentioned earlier, the epidural rate in this study was 22%, which is pretty low. The population was 93% white, and that was similar in both groups—the epidural group and the non-epidural group. However, there were quite a few differences between the epidural group and the non-epidural group. The epidural group was more likely to be made up of people having their first baby, the participants who had epidurals were more likely to be from an advantaged or privileged socioeconomic group, they were less likely to be a smoker, more likely to have a labor induction, more likely to be having multiples, and more likely to have comorbid health conditions. When it came to birth outcomes, there was a huge difference between the two and it wasn’t really discussed much by the researchers and not at all by the news media. If you look in Table 1, buried towards the bottom of all that data is the fact that 75% of the non-epidural group had a spontaneous vaginal birth, compared to only 37% of the epidural group. This means that the majority of the epidural group had a Cesarean, forceps, or vacuum delivery. So let me share some of those numbers specifically from Table 1. The non-epidural group had an emergency Cesarean rate of 15.2%. The epidural group had an emergency Cesarean rate of 30.6%. That is a doubling in the rate of emergency Cesareans. When it came to instrumental delivery, which means giving birth with the assistance of a vacuum device or forceps, 8% of the non-epidural group had a forceps or vacuum-assisted birth, compared to 27.5% of the epidural group having a forceps- or vacuum-assisted birth. Also, 1.2% of the non-epidural group needed obstetric maneuvers to rotate a mal-positioned baby, while 4.9% of the epidural group needed rotational obstetric maneuvers.

Unfortunately, the researchers from this study basically ignored all of these data points in their discussion, the numbers are there in Table 1 like I described, but in the paper’s results section they barely mention it on page 6, they kind of list it in a long list of factors at the end, and they don’t discuss it further. And the Cesarean and operative delivery rates were not discussed in the discussion or analyzed in any other way. They do mention in their discussion section that a Cochrane review based on randomized trials found no increase in the risk of Cesarean with epidurals (which we’ve discussed in this podcast), and maybe that’s why they felt they didn’t need to analyze or discuss the high Cesarean rate in the epidural group.

From my perspective, there are a couple reasons why the Cesarean rate and forceps/vacuum rate were so much higher in the epidural group in this study. First, the epidural group had significantly more first-time birthing people in the epidural group, and that’s probably a big reason why there was a higher Cesarean rate in that group. They also had twice as many labor inductions, although we don’t know how many of these inductions were medically indicated vs. elective. They also had slightly higher rates of pre-eclampsia and diabetes. But this is all speculation on my part, and since the authors didn’t explore this finding in any more depth, it’s hard for me to say much more except that I’m surprised they did not discuss these findings—unless they wanted to avoid attention being drawn to this matter. And, this would make sense if they were trying to de-stigmatize epidurals in the United Kingdom.

But going back to the main finding, that all the news outlets are discussing—the impact of epidurals on severe maternal morbidity. They did find that epidural use was associated with a reduction in severe maternal morbidity. The news outlets are focused on a risk reduction of 35%, which is what the researchers reported, and 35% sounds huge, but that’s relative risk. Relative risk is the decrease in risk compared to something else, and you have to do a math formula to put those numbers into real life context, or what we call absolute risk. So the overall rate of severe maternal morbidity was 4.3 events per 1,000 deliveries. That’s 0.43% if you prefer to look at percentages.

So, to do the math, with 4.3 adverse events per 1,000 births, we have to multiple 4.3 times 0.35 (that 0.35 stands for the 35%). So, 4.3 times 0.35 gives you 1.5. This 1.5 number is mathematically 35% of 4.3. Then you’re going to do a subtraction to lower the overall risk by that 35%—4.3 minus 1.5. We’re taking off that 35%. So, 4.3 minus 1.5 gives you 2.8 per 1,000. So, your risk of a severe maternal morbidity event in Scotland, goes from 4.3 per 1,000 overall to 2.8 per 1,000. This is all statistically significant, and at a population level, it’s a good thing to see the severe maternal morbidity rate go down. At an individual level, it might not make that much of a difference for your risk to go from 0.43% to 0.28%.

When they did those additional analyses looking at preterm birth and births where there was a medical indication for epidural, they also found an additional protective effect with epidurals in which the presence of an epidural reduced the risk of severe maternal morbidity in those situations.

In the end, this seems like a high-quality study to me. It is not a randomized trial, and its results are consistent with others that have found decreases in rare maternal complications with epidurals. This information is encouraging for those who want or need epidurals in labor, but it also should not be used to coerce birthing people into having epidurals, because the outcome they were studying was already quite rare. The individual risk decreased from 0.43% to 0.28% in this specific population. And there may be other benefits and risks associated with epidurals, some of which we’ve already talked about in this podcast, that were not examined in this study.

Personally, I think the media coverage of this study in the United States is overblown, but I think this PR strategy was on purpose, because of the difficulty of accessing epidurals in the United Kingdom and because of the fact that some women and birthing people are discouraged from having an epidural or delay tactics are used to prevent them from having one, and there are disparities in access to epidurals in the United Kingdom. But I think this study has limited usefulness in the U.S. where epidural rates already hover between 70-90% in many hospitals. If anything, it will be used possibly to coerce women into having epidurals, by telling them they can greatly reduce their risk—by 35%– of having severe complications, without disclosing that the risk is already quite low and without sharing the absolute risk numbers. So I hope you found this addition to the podcast helpful. I just knew I had to include it because if I didn’t, we would get bombarded with questions about it! But overall I don’t think this study changes the bottom line that we’re going to share about epidurals. I think the benefits, risks, and alternatives all stand. This study just gives us more info about this risk of rare complications, that are severe. And now I’m going to move on to sharing with you the professional guidelines.

So before we wrap up, I want to talk about some of the professional guidelines, because I think it’s powerful to have information about what the guidelines say. And often these are locked behind a paywall. So I wanted to share with you guidelines from three different organizations in the U.S. So the American College of Obstetricians and Gynecologists in the U.S. says that labor can be a source of pain and many people desire pain management for labor. They state that unless there is a medical contraindication, pain management should be provided to anybody who requests it regardless of their ability to pay, and should be available in all hospitals that provide maternity care. They affirm that the research has shown that regional analgesia does not increase the risk of Cesarean and should not be withheld because of this concern.

There are very few reasons why you might not be able to have an epidural, but contraindications that could result in not being able to have an epidural include heart disease, blood abnormalities, spinal, muscular, or neurologic disease, major liver or kidney disease, history of risk factors for anesthetic complications such as an allergy to anesthetics, and other medical conditions such as a history of organ transplant or sickle cell anemia. In terms of low platelets, if you have low platelets, you may be a candidate for regional analgesia depending on your platelet count and other risk factors. And this decision should be individualized with the birthing person and in consultation with their providers. Epidurals are safe if you have preeclampsia and with most other complications. They talk about how the risks to the baby in utero and afterbirth from analgesia should be weighed against the risks of untreated pain. There are risks to untreated pain, which can affect the baby. They also state that if there’s a situation where there needs to be an emergent Cesarean, if you have an existing epidural, you’ll need a bolus dose to get a higher concentration into the epidural catheter.

If you’ve not yet received an epidural, then a spinal, a combined spinal epidural or general anesthesia may be used for an emergency Cesarean. Another organization I wanted to share some of the guidelines from is the Association of Women’s Health, Obstetric and Neonatal Nurses or AWHONN. AWHONN states that anesthesia should be individualized during labor based on the stage of labor, your discomfort and your baby’s status. Because severe pain has the potential to lower oxygen to the fetus, analgesia can help with this. AWHONN provides recommendations for regional analgesia and they have ratings in their guidelines from weak to strong alongside the strength of the evidence. When you look at their specific recommendations, they also separate different recommendations based on stage in the labor process, such as preparation, uterine activity, fetal heart rate patterns, and the second stage of labor. Some examples of AWHONN strong recommendations for each stage. In preparing for analgesia, they recommend that nurses verify that informed consent has been obtained. Assessing the baby’s status and the birthing person’s vital signs and labor progress, and that an RN should be with the patient from initiation of epidural to more than 30 minutes afterwards. During that time, the nurse should be assessing your blood pressure, assessing for adverse reactions, and intervening as needed to address low blood pressure. For example, turning you onto your side. They also should be assessing fetal heart rate and uterine activity every five minutes for the first 15 minutes after the analgesia is started, and to, on an ongoing basis, monitor you for signs of sedation or slowed down breathing. They also state that nurses should be assessing for urinary retention at least every four hours and assisting with bladder emptying as needed. Something worth noting is that AWHONN provides a moderate recommendation supported by medium evidence that nurses assess and support oral intake of fluids and food as desired by low risk laboring women. And we talk more about the evidence on eating and drinking with an epidural in EBB episode 233. Also in our Signature Article on eating during labor at EBBirth.com/eating. 

Also, the American Society of Anesthesiologists has some interesting guidelines that they developed in coordination with the Society for Obstetric Anesthesia and Perinatology. Their guidelines are very comprehensive and provide recommendations ranging from evaluating someone before they get anesthesia and management of emergencies and everything in between. Overall, about epidurals and regional analgesia, the American Society of Anesthesiologists recommends that people should have the option of regional analgesia regardless of where they are in the dilation process. So even if they’re in early labor before five centimeters dilated, people should have the option. They also recommend offering regional analgesia to people attempting a VBAC and to consider inserting the catheter early if there is a complicated labor such as with twins, preeclampsia, or they anticipate that it might be difficult to intubate you if you needed an emergency Cesarean. The ASA states that a continuous epidural infusion may be used for effective analgesia or that you could use a single injection spinal, but this is time limited. So they state if labor is anticipated to be longer or if there’s a chance for Cesarean, consider using the epidural catheter technique instead. And then they do recommend the combined spinal epidural technique as being effective and rapid onset pain management for labor.

They also state that patient-controlled epidural analgesia or the PCA pump is also effective and flexible and may help lower the amount of dosage that you may need. I wanted to point out a note that although they recommend use of an epidural for a VBAC, that this by no means means that you have to accept this. As with any intervention that we talk about at EBB, you have the right to informed consent and informed refusal. So we’ve covered a lot today about epidurals. And what’s the bottom line? So I think the bottom line is that epidurals, spinals, and combined spinal epidurals during labor are all effective ways to help manage pain. Rates of epidural use vary depending on culture and practice patterns. And although epidurals are common and effective, they do carry potential risks and side effects. And there are alternative methods of managing comfort level that could be used instead of an epidural, before you have an epidural, or even after you’ve been given an epidural.

We talk more about non-pharmacologic approaches to pain relief in our EBB childbirth class and our Pocket Guide to Comfort Measures, but one of the benefits of adding non-medication approaches is that they typically have no side effects and you can always opt for an epidural if you need additional help coping with labor. 

So I hope this overview podcast was helpful for you. Next month we’re going to be releasing another podcast all about the impact of epidurals on the pushing phase. And then the following month we’re going to talk about the impact of epidurals on lactation. So stay tuned and in the meantime feel free to check out all the resources we have on pain management at our website. We’ll link to those in the show notes. And thanks so much everyone for listening. I’ll see you next week. Bye!

Today’s podcast was brought to you by the Signature Articles at Evidence Based Birth®. Did you know that we have more than 20 peer-reviewed articles summarizing the evidence on childbirth topics? Available for free at evidencebasedbirth.com. It takes six to nine months on average for our research team to write an article from start to finish. And we then make those articles freely available to the public on our blog. Check out our topics ranging from advanced maternal age to circumcision, due dates, big babies, pitocin, vitamin K, and more. Our mission is to get research evidence on childbirth into the hands of families and communities around the world. Just go to evidencebasedbirth.com, click on blog. And click on the filter to look at just the EBB Signature Articles.


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