by Kim Wildner
The January 11, 2012 Slate.com article The Truth About Epidurals: Are they really so bad? by Melinda Wenner Moyer concludes with this paragraph:
"Women shouldn’t cave to pressure from either side." [Of the 'mommy wars' between natural birth advocates and pro-epidural advocates] "They should make informed decisions based on their goals and priorities. I aspired to have a comfortable birth even if it meant being surrounded by nurses and doctors and tubes and incessant beeps; other women may trade pain for a more intimate birthing experience. Each choice comes with its own benefits and unpleasantries. My unnatural childbirth left me with a memory that does not involve intolerable pain, and that’s exactly what I wanted."
I’m concerned about this piece for a number of reasons, but the most significant are summed up in this paragraph, so I’d like to start here.
I agree that women should make their own best and informed decisions. I object to the continued polarization of ‘us’ and ‘them.’ I also disagree with the characterization of the options as choices between benefits and ‘unpleasantries.’ This minimizes that in consideration of birthing options we must weigh benefits and risks. This includes risks to babies as well as ourselves. Thus, while the decisions very well may be based on ‘goals and priorities’ I would argue that the highest priority must be the health and well-being of the mother-baby dyad. Reducing the choice to that of comfort vs. an 'intimate' experience ignores that many women choose natural birth not because of the 'experience' but to minimize risk.
Every intervention was introduced for a valid reason and when used appropriately, has the potential make a difficult birth better. That does not mean every intervention is appropriate for every situation. When used inappropriately, every intervention has the potential to also cause problems. This includes epidurals and other labor drugs. To suggest otherwise and is disingenuous...and a huge disservice to those trying to make an informed decision.
I spent hours trying to look up the studies that the author mentioned but failed to cite. I did not find her references, but she was correct in her assertion that the evidence is ‘inconclusive.’ The vast majority of studies do say that rates of surgical deliveries increase due to a multitude of reasons involving epidurals. A handful suggested otherwise.
So I went to The Cochrane Collaboration, the largest independent collection of available medical studies, encapsulated in A Guide to Effective Care in Pregnancy and Childbirth. This source states, “In women with epidural analgesia, both the first and second stages of labor are longer, and oxytocin use, malrotation and cesarean sections are more frequent.” (Enkin, et al p. 291)
The Cochrane Collaboration last updated in 2011 states:
"The review identified 38 randomised controlled studies involving 9658 women. All but five studies compared epidural analgesia with opiates. Epidurals relieved labour pain better than other types of pain medication but led to more use of instruments to assist with the birth. Caesarean delivery rates did not differ overall and nor were there effects of the epidural on the baby soon after birth; fewer babies needed a drug (naloxone) to counter opiate use by the mother for pain relief. The risk of caesarean section for fetal distress was increased. Women who used epidurals were more likely to have a longer delivery (second stage of labour), needed their labour contractions stimulated with oxytocin, experienced very low blood pressure, were unable to move for a period of time after the birth (motor blockage), had problems passing urine (fluid retention) and suffered fever. Long-term backache was no different. Further research on reducing the adverse outcomes with epidurals would be helpful." (Anim-Somuah, Smyth & Jones, 2011)
Cesarean rates did not increase overall, but risk of cesarean section for fetal distress was increased? The experience of very low blood pressure often leads to fetal distress which leads to surgical birth. If a complication can be directly attributed to the epidural, and it leads to emergency surgery, is the surgery then considered due to a medical complication instead of the epidural, even though the complication would not have occurred in the absence of the epidural? If a study does not compare natural birth to medicalized birth, how can any conclusions be drawn about how the interventions impact a birth?
And does it matter if the research is possibly tainted by special interests anyway?
Dr. Marcia Angell, the Editor of the New England Journal of Medicine, said in 2009:
"It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine." (Angell, 2009)
When looking at the evidence in trying to make a decision as important as that regarding the long term health of our children, this should lead consumers to ask: Where is the funding for a coming from and who is performing it?
Who loses revenue or might be out of a job if tools like epidurals are used sparingly? I hear a lot of disparaging remarks about natural birth advocates, but what do they have to gain by questioning the safety of labor drugs?
Wenner Moyer suggests that we compare the objective evidence with “...the reassuring words of obstetricians and anesthesiologists who tout epidurals as being completely safe.” What makes her think that her doctor or anesthesiologist is making a recommendation on scientific evidence anyway? Reading the summary of ACOG recommendations for suspected fetal macrosomia (big baby) 2/3 of obstetrical recommendation not evidence-based! (Chatfield, 2001) A Guide to Effective Care in Pregnancy and Childbirth reveals this is hardly unusual.
If we are only asking ‘Do epidurals effectively reduce or eliminate pain?’ and ‘Is there 100% consensus on safety?’ Wenner Moyer’s article addresses those questions. That is also providing that the only thing one is concerned about is whether the mother will end up with a surgery that has a 5 times greater mortality (death) rate than natural birth. But what about other consequences of epidurals? And what about just a little bit of plain old common sense.
My best fell down a flight of stairs at 40 weeks, 4 days. At the hospital it was determined her baby was fine, but she had a broken tailbone. She asked for something for the pain and was told there was nothing they could give her that was safe for the baby. BUT if they would just let them induce her, she could pain relief. She asked them to just give her what they would give her in labor. If it would help then, why couldn’t it help now? They refused. She asked, ‘You can create pain with an induction and give me something for the pain you create, but you can’t give me the same drug for the pain I’m in? What kind of sense does that make?” They couldn’t answer that. She declined to be induced.
If any mother were to test positive for a narcotic or cocaine, do you think there would be negative consequences? If a mother who had an epidural would have in her body a 'caine derivative, lidocaine, not approved by the FDA for use in pregnancy, labor, delivery or lactation, but used none-the-less. Or she might have narcotics like Stadol or Mepergan, also not approved for use in labor, but used often. Again, a drug is a drug is a drug and the effects are the same. It doesn’t change because it’s administered by a nurse or anesthesiologist.
Stating the obvious does not mean that an epidural is never helpful or necessary. Stating the facts is not guilt inducing any more than stating that grass is green should make someone who is colorblind feel guilty because they see it as yellow or blue. The fact is grass is still green.
This brings me to the notion that birth is always excruciating. If the debate is framed in such a way as to present the only choice as excruciating pain or completely safe numbness, it would seem crazy to opt for natural birth as opposed to risk-free drugs. Except that that isn’t being honest and those aren’t the only options.
As a HypnoBirthing® instructor with more than 20 years experience in childbirth I expect a birth to fall somewhere on a continuum: A few ecstatic and/or orgasmic; about 30% painless without drugs; the vast majority mostly comfortable with either manageable discomfort or complete comfort throughout until the last hour or so; some that are painful, but empowering instead of insufferable; a few epidurals; a few cesareans. Some women will be upset with a 45 minute labor. Some will be perfectly happy with 3 days back labor ending in a cesarean. Interpretation of circumstance is what we make of it. Perception is reality.
When women are confident that they are fully capable of making the best decisions for themselves no matter what situation is presented, because they made their decisions on the actual events specific to them and not an imagined potential reality, they do not feel a need to defend their decision. What I teach is evidenced-based and geared toward that end, but it still won’t be applicable to every child, mother or family.
I advocate for natural birth and breastfeeding because of the benefits it conveys. It makes life easier, MOST OF THE TIME if we do not try to fight nature. But if it is not benefiting the mother and baby, or if the mother just does not want to avail herself to the benefits and prefers to create difficult situations, that is her prerogative. I don’t think it’s fair, to say of excruciating, dysfunctional labor, ‘this is what birth always is’ when so many difficulties are created, not encountered.
Parenting comes with enough challenges without having to deal with ones that might have been avoided! One of the best ways to avoid the pitfalls is to take an independent childbirth class. Each year, 1 million out of 4 million birthing women will take a class at all. Of those that do, most will take a ‘prepared childbirth’ class offered by their hospital. I’ve taught those classes, and I can tell you they exist to make life easer for the hospital, not the parents. Think about it: If “60-80 percent of first-time pregnant American women’ get epidurals do, as Wenner Moyer suggests, then the classes are doing a pretty poor job of preparing anyone for anything other than when to get their epidural.
I pass on evidence-based information for those that want it. In doing so I hope to make life easier for women, babies and families. But if the evidence-based isn’t easier, or possible, or simply not wanted, ignore it.
Because ultimately, the key to ending the phenomenon we know as ‘The Mommy Wars’ is to make your own best decisions based on all the (independently verifiable) information available at the time, tempered with commonsense based on individual situations.
No one else lives your life. No one else is responsible for the consequence of your actions. It doesn’t matter what you do, someone is going to think you are doing it wrong. The key to not letting that bug you is to be sure of your decisions, and know WHY you are making them. If it’s something someone else considers unsafe, like home birth in my case, make damn certain you know it IS safe, at least for your situation. That way if someone does accuse you of being a bad parent, you can actually use it as a teaching moment instead of getting your knickers in a twist.
AIMS. (Alliance for the Improvement of Maternity Services): Drugs not FDA approved for obstetrics http://www.aimsusa.org/ObstetricDrugs-NotApproved.htm
Angell,M., 2009. Drug Companies & Doctors: A Story of Corruption. The New York Review of Books. http://www.nybooks.com/articles/archives/2009/jan/15/drug-companies-doctorsa-story-of-corruption/
Anim-Somuah M, Smyth RMD, Jones L., 2011. Cochrane Supparies: Independent high-quality evidence for health care decision making. Epidurals for pain relief in labour. http://summaries.cochrane.org/CD000331/epidurals-for-pain-relief-in-labour
Chatfield, J., ACOG Issues Guidelines on Fetal Macrosomia, Am Fam Physician. 2001 Jul 1;64(1):169-170. Retrieved from http://www.aafp.org/afp/2001/0701/p169.html
Enkin, M., Keirse, M., Neilson, J., Crowther, C., Duley, L., Hodnett, E., Hofmeyr, J., A Guide to Effective Care in Pregnancy and Childbirth, 3rd edition, 2000. Oxford University Press, USA.
Wenner Moyer, M., 2012. The Truth About Epidurals: Are they really so bad? Posted Jan. 11, 2012, at 3:28 PM http://www.slate.com/articles/health_and_science/medical_examiner/2012/01/the_truth_about_epidurals.html
Kim Wildner is the author of Mother’s Intention: How Belief Shapes Birth and creator of Fearless Birthing™, workshops designed to assist birth-workers in facilitating evidence-based decision-making in their clients. She has been published in a number of birth related trade journals and spoken internationally with her latest speaking engagement at National University Hospital in Singapore. Wildner has more than 20 years experience in childbirth education and passed the North American Registry of Midwives (NARM) exam in 1993. She has been a HypnoBirthing® Certified Educator for over 10 years and holds a BA in Organizational Communications.