Some of you may be aware of a recent publication by a Dr. Gilbert Grant, a U.S. anesthesiologist, titled Epidural without Guilt: Childbirth without Pain. Dr. Grant has been making his rounds of childbirth websites and promoting himself and his perspective on epidurals, which is: the earlier,the better, and why not get one while breastfeeding too? Dr. Grant has obvious self-interest in these perspectives, but his perspective is also a reflection of a larger societal belief, which is that epidurals have no risks, and why would any woman want to ‘suffer’ through the pain of childbirth when this amazing pain relief is readily available?
Another doctor who likes to make her view known online, OB Dr. Amy Tuteur of the U.S., is also very clearly in favour of epidurals, and even sees it as a feminist issue–as in, why are women being fooled into believing they somehow deserve this pain and should go through it? Is there any pain that we believe men should ‘have’ to go through, for the benefit of themselves/their children?
On the other hand we have Dr. Michael Klein of the University of British Columbia and Vancouver Women’s Hospital providing evidence-based information about the risks of routine epidurals, and examining closely some of the studies that have been done and the way epidurals have transformed birth. Of course, we like him already because he’s Canadian 
He also points out that epidurals can be beneficial when used to solve specific problems, and in these cases may actually help women and babies to avoid some of the risks they would encounter with a routine epidural.
He also points out that epidurals can be beneficial when used to solve specific problems, and in these cases may actually help women and babies to avoid some of the risks they would encounter with a routine epidural. Dr. Klein has recently completed a study of the attitudes and beliefs of maternity care providers across Canada, which revealed that (alarmingly, I think) over 35% of family doctors and over 50% of obstetricians (in some cases up to 70%) are not aware of the risks of routine epidurals: 1.5 – 3.5 times the risk of vacuum/forceps birth, longer labours (on average 5.7 hours longer), and twice the risk of malposition of the baby with an early epidural. They were not asked whether they believed epidurals increased the risk of episiotomy/severe perineal tears, but research shows that a woman who has an epidural has twice the risk of episiotomy and/or 3rd or 4th degree perineal tear. Almost 60% of OBs and over 35% of family doctors believe that epidurals should be routinely offered to all women. (See below for references for increased risks).
So obviously there is controversy here. There are political and ‘traditional’ reasons why many doctors believe that epidurals have very few risks, the main one in my opinion being that epidurals have transformed birth so greatly that many nurses and doctors rarely, if ever, see a woman without an epidural. So their main body of experience in the birthing process is managing care of women with epidurals, and this is their ‘normal.’
Why are so many doctors unaware of the research? I really have no idea. Perhaps part of the problem is that, unlike a randomized controlled trial (RCT) to test a new drug, studies of birthing practice and outcomes are by nature extremely complex, and greatly affected by the birthing environment, whether the study is an RCT or not. I’ll be writing an article Epidurals: The Controversy to discuss some of this complexity. But the scary part is that most women also have large knowledge gaps when it comes to epidurals (and other important interventions). Dr. Klein recently completed a survey of women pregnant with their first baby, and found that a significant portion of women had knowledge gaps, regardless of their care provider, but especially those seeing an OB or a family doctor. (This research is in press, and will be published in the Journal of Obstetrics and Gynaecology Canada, June 2011).
When you combine the maternity care provider’s lack of knowledge and the woman’s lack of knowledge you get a black hole instead of informed decision-making.
And that, my friends, is a feminist issue.
Look for Epidurals: A Feminist Issue next week here at the Mothers of Change blog!
References
Increased risk of vacuum/forceps
Howell C. Epidural versus non-epidural analgesia for pain relief in labour. In: The Cochrane Library, Copyright 2004, The Cochrane Collaboration; 2004.
Hoult I, MacLennan A, Carrie L. Lumbar epidural analgesia in labour: relation to fetal malposition and instrumental delivery. British Medical Journal. 1977;1:14-16.
Longer labours
Howell C. Epidural versus non-epidural analgesia for pain relief in labour. In: The Cochrane Library, Copyright 2004, The Cochrane Collaboration; 2004.
Increased risk of malposition
Klein MC, Grzybowski S, Harris S, Liston R, Spence A, Le G, et al. Epidural analgesia use as a marker for physician approach to birth: implications for maternal and newborn outcomes. Birth 2001;28(4):243-8.
Hoult I, MacLennan A, Carrie L. Lumbar epidural analgesia in labour: relation to fetal malposition and instrumental delivery. British Medical Journal. 1977;1:14-16.
Increased risk of episiotomy and/or severe perineal tears
Carroll TG, Engelken M, Mosier MC, Nazir N. Epidural analgesia and severe perineal laceration in a community-based obstetric practice. Journal of the American Board of Family Practice 2003;16(1):1-6.
Robinson, JN, Norwitz ER, Cohen AP, McElrath TF, Lieberman ES. Epidural analgesia and third-or-fourth-degree lacerations in nulliparas. Obstet Gynecol. Aug 1999;94(2):259-262.
{ 5 comments… read them below or add one }
So, how long before Dr. Amy finds this and gives her 2 cents? *eye roll*
I noticed that my views were mischaracterized on your site. I have never said, nor have I ever insinuated that epidurals have no risks. My position is, after studying this subject for more than 25 years, that the risks of NOT getting an epidural may be greater than the risks of getting one. Each woman needs to decide for herself what type of pain relief (if any) she wants for her birth experience. But to make that decision she needs to know the facts. Open-minded women find the data I present quite compelling. Of course, it is ultimately they, not I, who decide what course they choose.
This is really totally beside the point, but that photo really skeeves me out. I would rather not have someone inject something into my spine (or epidural space, but you get the picture) if it weren't totally necessary. And thankfully, through two births, I have not yet found it to be necessary (for me).
Hi Gilbert, I thought we'd see you on here. I'm glad you acknowledge that epidurals have risks, and I hope you acknowledge that they go beyond the possibility of headache and paralysis, and that routine and especially early epidurals have very real, negative impact on the physiological process of birthing.
An epidural can be useful to solve a specific problem, such as an exhausted mother who has been birthing for a long time, is at 8 cm, and has a malpositioned baby–in this case the epidural may help the mother get some sleep, the baby may get into a better position, and they might avoid a cesarean or vacuum/forceps birth.
I agree that women need to be informed about the facts in order to make the choice that is right for them, and this includes being aware that there is controversy and ambiguity around some of the research.
The research is quite clear, however, that epidurals interfere with the hormonal, physiological process of birth, and a woman who requests an early epidural can expect a cascade of other interventions.
I'm sorry, but where did you find that epidurals increased the length of labor an average of 5.7 hours? That Cochrane Review that you cite found there is no statistically relevant evidence that they increase the first stage of labor (the quotes are from the actual paper):
"Length of fi rst stage of labour:
Nine trials, involving 2328 women, reported on this outcome. There was no evidence of a significant difference in this outcome."
And that the difference in the second stage was 15.55 min:
"Length of second stage of labour:
Eleven trials involving 3580 women reported this outcome. Women with epidural analgesia had a statistically signi cant longer second stage of labour (WMD 15.55 minutes, 95% CI 7.46 to
23.63, 11 trials, 3580 women)."
That is hardly 5.7 hours.