Epidurals--Real Risks for Mother and Baby (excerpted)
by Sarah Buckley, Brisbane, Australia
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 (Ramin et al.,
Howell). The second stage of labour is particularly slowed, leading to a
three times increased chance of forceps (Thorpe et al.). Women having their
first baby are particularly affected; choosing an epidural can reduce their
chance of a normal delivery to less than 50% (Paterson et al.).
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 (Thorp, Meyer et al.)
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 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
25% of the women who take them (Lirzin et al. & Caldwell et al.): morphine
or diamorphine are most likely to cause this. Morphine also brings on oral
herpes in 15% of women (John Paull).
All opiate drugs can cause nausea and vomiting, although this is less
likely with an epidural (around 30% [ibid]) than when these drugs are given
into the muscle or bloodstream, where larger doses are needed. Up to a
third of women with an epidural will experience shivering (Buggy et al.),
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 (Camman et al.). 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 (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 (Kennell et al.).
There is a noticeable lack of research and information about the effects of
epidurals on babies. Drugs used in epidurals can reach levels at least as
high as those in the mother (Fernando et al.), and because of the baby's
immature liver, these drugs take a long time--sometimes days--to be cleared
from the baby's body (Caldwell, Wakile et al.). Although findings are not
consistent, possible problems, such as rapid breathing in the first few
hours (Bratteby et al.) and vulnerability to low blood sugar (Swantstrom et
al.) 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 (Enkin et al.). 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 (Smith, Walker) which may be a drug effect
or may relate to more subtle changes. Studies suggest that epidurals
interfere with the release of oxytocin (Goodfellow et al.) which, as well
as causing the let-down effect in breastfeeding, encourages bonding between
a mother and her young (Insel et al.).
(An edited version of this paper was first published in Australia's Parents
magazine, Aug/Sept 1998)
References:
-Buggy D, Gardiner J. The space blanket and shivering during extradural
analgesia in labour. Acta-Anaesthesiol-Scand 1995; 39(4): 551-553
-Caldwell LE, Rosen MA, Shnider SM. Subarachnoid morphine and fentanyl for
labor analgesia. Efficacy and adverse effects. Reg Anesth 1994;19:2-8
-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
-Camman WR, Hortvet LA, Hughes N, et al. Maternal temperature regulation
during extradural analgesia for labour. Br J Anaesth 1991;67:565-568.
-Enkin M, Keirse M, Renfrew M, Neilson J. A Guide to Effective Care in
Pregnancy and Childbirth. P 287 Oxford University Press 1995
-Goodfellow CF, Hull MGR, Swaab DF et al. Oxytocin deficiency at delivery
with epidural analgesia. Br J Obstet Gynaecol 1983; 90:214-219
-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)
-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
-Kennell J, Klaus M, McGrath S, et al. Continuous emotional support during
labor in a US hospital. JAMA 1991;265:2197-220
-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
-Paterson CM, Saunders NSG, Wadsworth J. The characteristics of the second
stage of labour in 25069 singleton deliveries in the North West Thames
Health Region. 1988. Br J Obstet Gynaecol 1992;99:377-380
-John Paull, Faculty of Anaesthetists, Melbourne. Quoted in: "The perfect
epidural for labour is proving elusive" New Zealand Doctor. 21 Oct 1991
-Ramin SM, Gambling DR, Lucas MJ et al. Randomized trial of epidural versus
intravenous analgesia during labor. Obstet Gynecol 1995; 86(5):783-789
-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; 70:791-800
-Thorp JA, Meyer BA, Cohen GR et al. Eppidural analgesia in labor an
cesarean section for dystocia. Obstet Gynecol Surv 1994; 49(5): 362-369
Reprinted from Midwifery Today E-News (Vol 2 Issue 7 February 18, 2000)
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