The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Epidural Risks

Risks of epidural anaesthesia - direct and indirect - some STATS for all they are worth....

generally, it is true to say the epidurals are a safe and effective method of relieving pain in labour - but safe does not mean risk free - the risks are there - it is wrong to say there are "none" (re the hospital employed childbirth educator) See Thorp, J.A. & Breedlove, G (1996) Epidural Analgesia in Labour: An evaluation of Risks and Benefits 23(2) 63-83. for a good review of the literature.

• hypotension 12 - 23%
• maternal fever - (then unnecessary antibiotic therapy - then the yeast infection - then.....) one study cited an increase of 0.07 Celsius rise per hour exposure to epidural anesthesia. another reported 5% of fetuses reached cores temp in excess of 4Celsius, another found a statistically significant increase in maternal temps > 38C associated with EA.
• inadvertent spinal ( and headache to follow - which a blood patch does not always cure - the incidence depends on skill of operator.... July - new residents - expect a huge increase in spinals in the teaching hospitals..... )
• pruritus, nausea and vomiting. (no numbers here - but more likely with spinals)
• backache - significant more women c/o backache following EA (RR 1.8)
• fluid overload- ?pulmonary edema???
• infection from epidural site
• resp arrest
• anaphylaxis
• nerve damage

• fetal distress- bradycardia - one study reported 11% occurrence within 5 - 20 minutes of administration
• dystocia (oft cited as reason for significant increase in C/S following epidurals)
• operative delivery (forceps, vac, C/S)
• episiotomy/tears
• oxytocin augmentation
• fetal scalp electrodes and IUPC use
• intrauterine infection - related to the increase in V/Es, IUPCs, etc. breastfeeding and infant behaviour - depending on amount of narcotic and anesthetic the baby has been exposed to.- the local anaesthetic from regional anaesthesia has been detected in cord blood following birth... - led one researcher to comment that epidural babies were floppy but alert....

I think that would influence most women's decision making here. They need to be aware of the "domino" effect - aka the cascade of interventions = once you get one - you get the works.... Much more accurate than saying "none" ..... when asked what are the risks of epidural anaesthesia... This hasn't even touched on the psychological impact of not "birthing" on your own - versus the powerful experience of an unmedicated birth...

I cannot forget to mention.... epidurals are a tool - like anything else - when used appropriately a very good thing. There is the rub... selective and appropriate use of a tool. Have you heard the old saying : "Give a man(sic) a hammer and everything becomes a nail"? (This is not exclusively male - It should read person...) I have seen epidurals used judiciously to help women deliver spontaneously. They sure beat general anaesthetic for operative birth.... and sometimes they are the best possible option. I guess we are all about supporting women in informed decision making - that also means that after we have done our job (given tons of info, support and encouragement that they are good and strong and birth is normal etc. -) and the women says - she still wants her epidural at 5 cm..... then we must respect that too - as much as it drives us crazy.... though I find that this so rarely happens when we have done everything we know we should.

The incidence of chronic back pain (lasting weeks to months) is reported at 10-15%.

Episodes of hypotension are quite frequent in my experience, despite IV fluid loading prior to the procedure. These frequently cause fetal bradycardias and all the resulting interventions, chaos, and fear.

I know one female OB/GYN doctor who had an epidural with her 3rd child and nearly died. The anesthesiologist (the mom/doctor wanted the MD rather than the nurse-anesthetists who do most of the epidurals in this facility) set the epidural pump at the wrong rate (by a factor of 10), the anesthesia level quickly ascended and the mom/doctor went into respiratory arrest.

Late decelerations (usually with good variability and referred to as "reflex lates") are a common sequelae of epidurals. They are not threatening in and of themselves, but they create a cascade of intervention.

Fever is not uncommon (about 20-25%, I believe) and can cause many interventions for mom and baby.

Spinal headaches are unusual in skilled hands, but I've seen them.

Vacuum and forceps delivery are significantly increased, as is cesarean section if the epidural is given before 4-5 cm.

I always include all these risks in my discussion of informed consent with the laboring woman and her family. I also talk about the necessity for Foley catheters, continuous monitoring, and the forced immobility. It's amazing how many women choose not to have epidurals when given full information. I do not make judgments about the women who do choose them. For some women, epidurals are the best thing since sliced bread. Some labors are so stressful, painful, and complicated that epidurals can make the difference and permit a vaginal delivery. But a lot of women opt to do without when they realize that epidurals are not magic solutions to the pain of labor.

Of course I always offer alternative pain control methods and encourage women to find ways to help themselves get through the labor process with a feeling of competence and joy.

Research and backpain following epidural

That is why researchers compared two groups - women with epidurals and women without - and they found a significant difference in the rates of backache between groups.

so - you can never be sure what "caused" the backache - just like you can never be sure what "caused" the dystocia, c/s, infection, fever etc. - we do know that you are more likely ( with statistical significance) to have these happen if you get an epidural. We can’t put our finger on the epidural for sure - Nor can you assume the opposite - that avoiding an epidural will negate these possibilities. It is really looking at relative risk.

Regarding the statistics that accompany the epidural epidemic.

I refer anyone interested in the subject to the book "Obstetric Myths versus Research Realities", plus the Journal of Nurse Midwifery has had some articles over the last year.

At our medical center were we have an 80% epidural rate with primips and a 25% instrumental birth rate for the same group, mostly because of transverse arrest.

I also personally know of a woman who is paralyzed because of nerve damage caused during an epidural (a hematoma pressing on a nerve), have seen one woman go into spinal shock-intubation and crash section, not to mention the good ole dip in the monitor 10-20 minutes after 30% of the epidurals are administered. Let's not forget the higher tear rates, higher epis rates, back aches, etc. What is the most amazing fact in the whole epidemic is that all our women have to sign consent after reading about all the possible side effects, including paralysis, and they still do it. Most of the husbands freak out, but these woman have gotten nothing from their childbirth preparation courses, except when to get an epidural and how to lay still in embryonic position while someone sticks you in your spine. The real pitiful ones are those who either because of fever or thrombocytopenia are refused an epidural and totally freak out. I better shut up now, even though I can rant about epidurals for a good 2 hours without stopping to catch my breath.

[from a British midwife]

I find your problem with an excessive use of epidurals quite culturally interesting. Our hospital probably has about a 20% epidural rate I reckon (and that includes the sections)( of course still considerably greater than your homebirthers 0% rate!), and on the whole I find the women I look after pretty resistant to the concept and taking them as their kind of 'well, if its really unbearable I suppose I might think about it...' last resort. And those that do take up the option are almost exclusively the British born/ English as a first language clientele... our refugee/ non english speaking communities wont touch them.

I wonder whether this is due to some attitude towards them on the part of our linkworkers who translate, or whether its simply these women have come from places where hospitals are somewhere you go to die and have an innate distrust of all medical procedures. Interestingly the hospital down t'road which serves a much more affluent white middle class community has an 80-90% rate. Although they are also offer the 'mobile' epidural which we have not quite got to grips with yet...

Increases Risk of Surgical Delivery

By ANGELA LA VOIE   

c.1996 Medical Tribune News Service

In a study of 1,733 women giving birth for the first time, researchers found that women who received an epidural were almost four times as likely to undergo a C-section as women who did not receive an epidural.

An epidural may necessitate a C-section by relaxing the pelvic muscles so much that a woman is unable to push properly during labor, the researchers noted in the study, published in the December issue of the journal Obstetrics and Gynecology.

Another possibility is that an epidural somehow prolongs labor beyond what is generally considered normal, prompting doctors to then perform a C-section, they suggested.

"This adds to the growing body of evidence suggesting that epidural anesthesia is associated with Caesarean delivery," said lead researcher Dr. Ellice Lieberman, an associate professor of obstetrics, gynecology and reproductive biology at Harvard Medical School in Boston.

Dr. Ruth Fretts, an obstetrician/gynecologist at Beth Israel Deaconess Medical Center in Boston, agreed.

"This does seem to suggest that there is an increased risk of C-section among women who receive epidural anesthesia," said Fretts, also an instructor of medicine at Harvard.

Fretts advised women to hold out before receiving an epidural for as long into labor as they can to minimize the need for C-section.

In the study, the risk of C-section was greatest among the 104 women who received an epidural during the first stage of delivery, when the cervix (located at the entrance to the uterus) fully dilates. This stage typically lasts 12 hours, although there is some evidence that it may last longer for women giving birth for the first time.

The second stage of labor - from full cervical dilation to delivery - generally lasts less than two and a half hours for women giving birth for the first time and no more than one hour for women who have given birth previously.

Fretts recommended that pregnant women become well informed about labor and delivery to better cope with childbirth.

She suggested taking a good prenatal class and learning how to relax during the first stage of labor. Relaxation techniques include walking, receiving a back massage and taking showers, according to Fretts. Taking frequent showers during labor helps the muscles relax and slightly alleviates the pain, she said.

"Also, narcotic anesthesia is available to help women cope with the work of labor," Fretts noted. "It doesn't significantly reduce the pain, but it helps women relax," she said.

Obstetrics & Gynecology (1996;88:993-1000)

Epidural Risks to Newborn

Thorpe et al. have done numerous studies and meta-analysis on randomized controlled prospective trials with epidural and have demonstrated very clearly that epidural dramatically increases the likelihood of surgical delivery (both forceps and C/S).

[from ob-gyn-l]

I have recently encountered 3 episodes of significant fetal bradycardia immediately following regional anesthesia. In all of these cases there was no maternal hypotension (BPs taken q 1 minute). In all of these cases the type of anesthesia was a combined technique -- intrathecal narcotics and epidural anesthesia. In one case the bradycardia resulted in an emergency C-section with delivery of a vigorous infant.

How many of you have seen similar cases? Do you believe that a combined intrathecal/epidural technique causes more of these bradycardic episodes than either of the other techniques alone? How do you manage these cases? How do you counsel patients regarding this potential risk during informed consent? What is the physiologic mechanism for this complication in the absence of maternal hypotension?

Although our anesthesiologists are now saying that the preload with fluid doesn't avoid hypotension as we once thought I still am not sure. I would make sure that the patient has received a fluid bolus of 500-1000cc. Would make sure that after placement they are not flat on their back. There is some data that while systemic blood pressure is maintained, organ perfusion like the uterus may be faced with hypotension or decreased perfusion. Obviously no way to truly tell on any individual patient. Finally, in terms of consent, I would prefer the person placing the epidural counsel the way they feel is right. If you note a lot of complications I would bring that to the attention of the anesthesiologists. I have seen very different types/"complications" of epidurals at the 3 major academic centers that I've been at and I think it relates to preloading and how rapidly the levels are brought up which relates to dose and volumes used.

I recently heard a presentation of one of our regional meetings which I believe was repeated at the 1997 SPO at which the perinatal group from Brown Women's and Infant Hospital. They performed maternal echocardiography on women in left lateral decubitus position who were receiving and being dosed with epidurals. Out of 10 subjects, two fetuses experienced significant bradycardia. In both of those two mothers maternal cardiac output dropped significantly in response to epidural dosing. In spite of the drop of maternal cardiac output, the peripheral (upper extremity) blood pressure remained in the normal range, no doubt the result of an intact and active vasoconstrictor mechanism. The placental bed has no similar vasoactive capacity and the drop in cardiac output is reflected in selective placental hypoperfusion resulting in the fetal bradycardia. This makes sense to me since often upper extremity blood pressure remains normal during these fetal bradycardic episodes.

See it often. My assumption is that despite no hypotension, there is interference with blood flow to placenta. I think they almost always respond to adrenaline ( ? ephedrine ) and/or patience.

This type of response which I refer to as "Prolonged Deceleration after Local Anesthesia" can be found following the injection of any local anesthetic agent. The mechanism is probably the same as that found to cause this response after paracervical block. It occurs more often after paracervical because the agent is injected so close to the uterine artery. Griess at Bowman-Gray in the 70's showed that if you put local anesthetic agents on the uterine artery of pregnant Ewes, it went into spasm, the uterus went into tetany and the fetal heart rate decelerated. C.P.Gibbs at Gainesville at the same time found that if added to a water bath with human uterine artery strips, the strips went into spasm. This usually occurs 6-12 minutes after the injection, lasts 8-12 minutes and returns to normal. The only action needed is to not repeat the injection later.

Does anyone truly believe that their patients are receiving "informed consent" from anyone prior to placement of the epidural? Our hospital actually had a maternal death, caused by electro-mechanical dissociation of the heart following epidural injection. I have always felt that the patient, in pain and sometimes narcotized, demands an epidural for pain relief, the anesthesiologist drags himself out of bed, wanders over to L and D, the epidural setup has been done by the nurse and he finds the patient writhing in pain, positions her, preps her skin and places the needle and administers a test dose, all before he has had a chance to do more than introduce himself. Of course the anesthesiologists think that epidurals are harmless, and still have not even acknowledged that they cause maternal fevers. Sorry, I will get off my soap box.

At my prior hospital, the anesthesiologists met with parturients during their prenatal visits. The patients saw a video, spoke with an anesthetist or anesthesiologist, and signed a consent form there. This avoided the issue of obtaining a consent in laboring patients.