The first time someone hears about unmedicated childbirth they often say something like “Why wouldn’t I get an epidural? I don’t want to feel all that!” We totally understand this reaction. And if you find yourself suffering from pain in labor, or in desperate need of some rest, an epidural might be just the thing to get you through. But an epidural always comes with some major and minor risks that we believe you should know about. It’s important in making an informed decision that you know all the facts: good and bad. The height of labor is a terrible time to learn about the risks of any medication, so we hope to help you understand them beforehand. We want you to be able to make an informed decision about whether and when you want an epidural during your labor.
The biggest risks of epidurals are thankfully the most rare. There have been cases of permanent nerve damage and even death in the early days of use. These risks and all the others are due to the drugs given and the way they are administered. A needle is used to insert a tiny catheter near your spinal cord, which is when physical injury is unlikely but possible to occur. Once the catheter is in place, the needle will be removed. When the medication starts, and every time you hit your epidural button, a painkiller like bupivacaine or lidocaine drips down the catheter with a mix of other medications. These extra medications are added to enhance the analgesic, make it last longer, and reduce certain side effects. Hospitals don’t usually disclose the blend they use, but it typically includes opioids. You can try asking your doctor or hospital administrator if you want to know exactly what you may be given.
Even with medication mixes designed to minimize side effects, you’re bound to experience some. For example, epidurals almost always lower your blood pressure. Occasionally they cause an extreme drop in blood pressure or a sudden fever–major safety concerns for you and your baby. More common side effects are drowsiness, difficulty moving (even with a “walking epidural”), shaking, and whole body itchiness. There is also the possibility that it won’t work correctly, leaving you too numb, only numb on one side, or not at all. In fact, a recent report shows that 1 in 8 people don’t feel like their epidural gave them the pain relief they wanted.
You also want to consider “side effects” such as the other interventions that always come with an epidural. They are a package deal that includes IV fluids, a urinary catheter, continuous fetal monitoring, and continuous oxygen monitoring. Both epidurals and continuous fetal monitoring are associated with non-reassuring fetal heart tones and other complications that your doctor may wish to treat with more interventions. This is a prime example of “the cascade of interventions”–the well-documented fact that having one medical intervention increases your chances of having another. There are two identified causes for this: first is that when you look hard enough for a problem, you will find one, such as with continuous monitoring of any kind (which research finds does not improve health for the parent or baby). The second is that once you have interfered with the natural process, it is less likely to proceed as designed, and more likely that further interference will be called for. So if you have a goal to avoid Pitocin, cesarean, or any other intervention, you may want to avoid an epidural as well.
Thankfully, there are a lot of non-medicinal ways to help manage labor. Moving around can help the baby rotate and descend while distracting you from the contractions. Regularly switching positions creates space for your baby to move down in different ways, and it is a good way to find poses that take pressure off your back or anywhere else that feels tense. Hot and cold compresses can do wonders for tight muscles and nausea. Entering a warm bathtub or shower can offer such great relief that it has earned the nickname “nature’s epidural.” However, you won’t be able to do any of this with an epidural because these natural methods become much more difficult or even dangerous when combined with the equipment and effects of an epidural.
Even with an epidural, there are some natural tools available to you. Peanut balls are perhaps the easiest and most effective. Using a peanut ball correctly helps open the pelvis even while you’re laying down or partially reclined. It gives you more options to change positions, which is still helpful to progress labor and let the baby descend. Alternatively, you can use stacks of pillows and support from your partner or doula to continue to change position. If you’re worn out from a long labor, resting in supported positions can give you excellent relief, maybe even between-contraction naps! While epidurals put you at increased risk for a c-section and longer pushing stage, using a peanut ball brings the risk of cesarean back down and can decrease the overall labor time (compared to epidural without peanut ball).
When it comes time to push, however, an epidural may prevent you from doing so in an upright or all-fours position, which decreases your risk of tears, episiotomy, and vacuum or forceps assistance. Yet we are all familiar with the image of someone lying on their back in a hospital bed to give birth! Ironically, this is generally the worst position to be in while pushing. If you have an epidural you may be discouraged or even forbidden from trying other positions, but with proper support from your birth team, you can take advantage of the adjustable bed and use props like your peanut ball to utilize a more beneficial position anyway.
There are two more drawbacks to pushing with an epidural. Firstly, unless the dose is very low, you will need to be coached through pushing. This usually sounds like “Take a deep breath! Hold it and push for ten! Nine! Eight!…” Pushing and holding your breath like this is called purple pushing. It is associated with unnecessary pelvic floor strain and an increase in issues like pelvic floor prolapse. Postpartum recovery is tough enough without extra complications! An epidural can be turned down or allowed to wear off completely before you push, making coached-pushing unnecessary and giving you the benefits of self-directed pushing. Be aware though: it can be difficult to cope with the sensation of contractions after being numb to them for any amount of time.
The other main complication of an epidural during the pushing phase is that you won’t feel the “urge to push.” If you wait for this instinct, it allows the baby to continue to rotate and move down from the force of the contractions alone. Even once you’re fully dilated, your baby may need to move further down before pushing is really helpful. When they’ve descended far enough that you get the urge to push, you will spend less time pushing and feel more productive in your pushes. This makes you less likely to become exhausted then need assistance from forceps, the vacuum, or even a cesarean.
The effects of the epidural don’t stop once the baby is born either. They have been linked to increased newborn complications such as low APGAR scores, resuscitation, and NICU admittance. Most babies born under epidural will not need to be whisked away, but they are more likely to be born sleepy from the small amount of drug that enters their body. They may be less alert and responsive to interact with their new environment, including nursing. Alert babies, placed on their parent’s chest and left alone may make their way to the nipple and latch instinctively! Holding your baby and letting them nurse during those first minutes is not just sentimental: it releases new floods of oxytocin to help you birth the placenta and contract the uterus so you don’t hemorrhage. Artificial oxytocin (a.k.a. Pitocin) can be administered to help with this, but it brings its own risks and side effects such as more painful contractions and further decreasing your natural oxytocin.
Even if your baby is too sleepy to nurse during the first hour, colostrum can be hand-expressed and fed to them with a spoon, or just as soon as they’re alert enough to get a good latch. This pre-milk substance coats your baby’s stomach, preparing them to digest food, prevent infection, and have their first bowel movements, preventing jaundice. It’s worth noting that babies whose parents were receiving IV fluids tend to have a bigger drop in weight during their first few days. This is not generally a problem but it is worth remembering–and perhaps reminding your provider–if your baby shows a slightly larger weight loss than expected. It’s probably not that your baby isn’t getting enough to eat, they just lost the extra water weight! You yourself may have a similar experience.
As things settle and the medical equipment is removed, any minor side effects you had should wear off. You will probably be sore at the epidural injection site for the next few hours or days, which can be treated with rest, hot or cold packs, gentle massage, and nursing-safe painkillers, like all the other tenderness or after-pains that come with birth. There is still a rare chance of experiencing a “spinal headache” in the days after your epidural. You should tell your care team right away if you have any migraine-like symptoms, as they may need to add fluid back into your spinal cord to treat it.
Despite these risks, there are still times when the positives outweigh the negatives. They do offer unparalleled pain relief which can change the trajectory of your birth. At their best, they alleviate suffering, reduce extreme anxiety, and offer rest to get you through a long labor. Likewise, knowing the possible risks of an epidural can make the difference between panic and calm if you experience them. We hope that sharing these risks and benefits helps you to make an informed decision, leaving you feeling confident and empowered through your birth.
Written by Lauren DePaul Trumbach exclusively for Moonchild Birth Services.
What is an Epidural?
Epidurals for pain relief in labour
Epidural during Labor for Pain Management
Intrapartum epidural analgesia and low Apgar score among singleton infants born at term: A propensity score matched study
Interrelations Between Four Antepartum Obstetric Interventions and Cesarean Delivery in Women at Low Risk: A Systematic Review and Modeling of the Cascade of Interventions
REDUCE THE RISK OF DEVELOPING PELVIC ORGAN PROLAPSE: BIRTHING TECHNIQUES FOR LESS STRAIN ON PELVIC FLOOR MUSCLES
Colostrum: What It Is, Benefits, and What to Expect
Reducing Length of Labor and Cesarean Surgery Rate Using a Peanut Ball for Women Laboring with an Epidural
An observational study of associations among maternal fluids during parturition, neonatal output, and breastfed newborn weight loss