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Childbirth Without Pain: Are Epidurals the Answer?

Is unmedicated natural childbirth a good idea? The American College of Obstetrics and Gynecology (ACOG) points out that

There is no other circumstance in which it is considered acceptable for a person to experience untreated severe pain, amenable to safe intervention, while under a physician’s care.

It is curious when an effective science-based treatment is rejected. Vaccine rejecters have been extensively discussed on this blog, but I am intrigued by another category of rejecters: those who reject pain relief in childbirth. They seem to fall into 3 general categories:

  1. Religious beliefs
  2. Heroism
  3. Objections based on safety

1. “In pain you will bring forth children” may be a mistranslation, and it certainly is not a justification for rejecting pain relief. Nothing in the Bible or any other religious text says “Thou shalt not accept medical interventions to relieve pain.” Even the Christian Science church takes no official stand on childbirth and its members are free to accept medical intervention if they choose.

2. The natural childbirth movement seems to view childbirth as an extreme sport or a rite of passage that is empowering and somehow enhances women’s worth. Women who “fail” and require pain relief or C-section are often looked down upon and made to feel guilty or at least somehow less worthy.

3. I’m not impressed by religious or heroic arguments, although I support the right of women to reject pain relief on the autonomy principle. What inquiring science-based minds want to know is what the evidence shows. Does avoiding medical treatment for pain produce better outcomes for mother and/or baby? It seems increasingly clear that it doesn’t. A new book, Epidural Without Guilt: Childbirth Without Pain, by Gilbert J. Grant, MD, helps clarify these issues.

Some of his points:

  • Not providing adequate pain relief is inhumane.
  • A large percentage of women who attempt childbirth without medication find the pain intolerable and end up asking for relief.
  • Pain should be treated early, ideally before it even develops. The dentist doesn’t wait to inject Novocain until you feel the pain and complain.
  • Excellent pain relief can be provided by epidurals with a high degree of safety. No other method is as good.
  • There is no justification for outdated practices of delaying epidurals until cervical dilation is advanced or for stopping the epidural during the last stages of labor.
  • Non-epidural analgesia is arguably less safe than epidurals.
  • Many safety objections to epidurals are based on outdated information about older techniques. New epidural/spinal techniques use a combination of low-dose anesthetics and narcotics to abolish pain without interfering with muscle function. They do not prolong labor or increase the need for instrument-assisted deliveries, and they allow patients to control the dose and to get up out of bed and walk around.
  • Epidural catheters can be left in place to better treat post-partum pain.
  • If an emergency C-section becomes necessary, having an epidural in place can speed the preparations for surgery.
  • Current data indicate that epidurals may actually speed up labor and have other health advantages.

He doesn’t deny that epidurals can cause adverse effects (from low blood pressure to spinal headaches). He discusses all reported complications of epidurals, explains them, and puts them into context with the adverse effects of other methods and with the adverse effects of unrelieved pain. Unrelieved pain during labor and post-partum has been shown to

  • Cause stress responses that can reduce the baby’s oxygen supply
  • Increase the risk of post-partum depression and post-traumatic stress disorder (PTSD)
  • Interfere with breast-feeding
  • Increase the risk of development of chronic pain conditions

A 2005 Cochrane review of studies comparing epidurals to other or no analgesia found a small increased risk of instrument-assisted delivery but no increase in the rate of C-sections, no effect on neonatal outcomes, and greater maternal satisfaction. The increased risk of instrument-assisted deliveries is not seen when newer epidural techniques are used.

In evaluating the literature, we must remember that epidurals have improved, and earlier studies looked at higher doses and less safe epidural practices.  Another confounder is that patients with problematic labors are more likely to ask for pain relief, so some of the complications previously attributed to epidurals might well have been due to other factors. I was particularly intrigued by one study he cited about a natural experiment. In 1993 the Department of Defense mandated that epidurals should be available on demand. At the Army hospital studied, the epidural rate went from 2% to 92%, but the rate of forceps deliveries and cesareans did not change.

Childbirth is a subject that seems to bring out the worst in strongly opinionated people. When I last checked Amazon.com, there were 4 reader reviews of this book. One was a gushing 5-star testimonial by a patient and friend of the author and the other three were 1-star emotional attacks on him for allegedly presenting inaccurate information and having a self-serving agenda for financial benefit. In reality, his information is accurate, is supported by the literature, and his conclusions are echoed by the ACOG and by a Clinical Therapeutics review article in the New England Journal of Medicine.

In my opinion, it is unconscionable to let patients suffering from severe pain go untreated unless there is compelling evidence that not treating pain results in improved health outcomes. It is even more unconscionable for ideologically motivated people to influence a patient to feel guilty about accepting pain relief. A typical natural childbirth website tells women that if they try but can’t stand the pain, they shouldn’t feel bad about asking for medication. The very fact that they felt compelled to say that is an admission that some women do feel bad. Alarmist midwifery websites ask “Why are so many women taking dangerous drugs during labor?” They  exaggerate the dangers of epidurals, referring to doctors as “drug pushers.” They tell women they should “embrace the full pain of childbirth.

Novocain is a potentially dangerous drug, but can you imagine a dentist telling a male patient to “man up” and have a root canal procedure without any anesthetic?  Because it will be safer? Because embracing the pain will be empowering?

A double standard? Misogyny? Ideology? The “natural fallacy”? Gullible acceptance of anti-establishment myths and misconceptions? Whatever is going on, Dr. Grant offers a science-based corrective. He provides complete and accurate information in an accessible format so that pregnant women can understand and give informed consent. Some will cry “bias” and “cui bono” since he is an obstetric anesthesiologist, but I think his presentation is fair and supported by the published evidence. Is he motivated by money and self-justification, or is he a good doctor who is sincerely concerned for the best interests and comfort of his patients? What’s wrong with aspiring to give all your patients a pain-free birth experience using the safest possible science-based state-of-the-art methods?

Disclaimer:  I have no dog in this fight. As a family physician I delivered around 200 babies. I never gave an epidural (because I was not taught how), but I received one for my first baby.  For my second baby, epidurals were not available and I was given a paracervical/pudendal block. Both methods worked.

Posted in: Book & movie reviews, Obstetrics & gynecology

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79 thoughts on “Childbirth Without Pain: Are Epidurals the Answer?

  1. Paddy says:

    Like the article. Incidentally, you may find this debate in response to a previous blog post on the topic interesting:

    http://blogs.babble.com/being-pregnant/2011/02/09/epidural-advocate-says-we-should-get-epidurals-after-the-birth-too/

  2. AlexisT says:

    There’s also a 4th “category”: People who don’t have a principled objection to epidurals, but simply don’t want them or believe the downsides of epidural outweigh the value of pain relief. That is, they don’t want to be immobile, continuously monitored, hooked up to an IV, have a urinary catheter placed, and have to wait for the epidural to wear off afterwards. Or they’ve heard too many stories of epidurals gone wrong. Or they simply are afraid of having needles near their spine unless it’s really necessary.

    I am not anti-epidural and think that many of the risks of epidural are exaggerated (and that anti-epidural advocates exaggerate the frequency of complications and epidural failure) but to me, saying that the cost-benefit analysis fails for you personally is a different kind of argument. (I am not talking about me personally–I have never labored and have no idea what I’d actually do.)

    Dr. Grant is currently engaged in a rather futile discussion of his book on MDC (in the “Birth Professionals” subsection of Birth and Beyond, if you care to look).

  3. Ziggy66 says:

    Given that much of the pain experienced in child birth is caused by human’s larger brain and skull and subsequent intelligence, it seems only natural that we use that intelligence to relieve that pain.

  4. Interestingly, the link you give for the possible mistranslation of Eve’s curse explains that childbirth is not intrinsically painful. Supposedly, complications of childbirth were very rare in biblical times. If we think childbirth is painful today, it’s only because we’ve been conditioned by bad translations.

    I don’t read that source as supporting pain relief in childbirth. I read it as disparaging women who experience pain as insufficiently biblical.

  5. Epinephrine says:

    My wife was very happy with her choice of home birth, and certainly the literature supports her decision. A recent study (2009) that was done in our province showed that there were reductions in the number of 2-4th degree tears, reduction in labour augmentation, in caesarian section, blood loss > 1000mL.

    More to the point, she was more comfortable at home, and was able to relax in her bed with her family around her soon afterwards. There is value in comfort and feeling secure, especially when it comes with a lower risk of complications, despite feeling more pain. Epidurals are not available at home births, perhaps if they were she may have opted for one. Studies trying to isolate the effect of the epidural alone aren’t of as much relevance if there are advantages to a home birth that perforce come with the lack of an epidural. The fact is that as with many things, the comfort level of the patient is important, and there is more to comfort than just pain.

  6. I would like to point out that my Lamaze instructor helped spread this outdated information about epidurals blocking muscular contractions and slowing childbirth and increasing the rate of c-sections. I was well against it going in, and I guess I was fortunate that my baby’s presentation required a c-section, otherwise I’d have gone unmedicated, too.

    It’s going to be a long haul spreading the new data to all the sources of misinformation out there, even assuming they will accept it.

  7. jude2004 says:

    I gave birth 3 times without pain medication. I recently watched someone on TV give birth with an epidural. It was interesting, but it didn’t make me change my mind about getting drugs. It hurts like hell to give birth, but I never saw the need for pain relief. I’m probably more anti-medication than most people. I suffer from chronic pain because I have scoliosis. I exercise to help with the pain. I don’t get headaches, but if I get a stiff neck, I stretch it out. I probably take aspirin 4 times during an average year. That woman I saw on TV feared the pain. She’d had a previous epidural that didn’t work, so she hadn’t been prepared for the pain. I feared it too, the first time. For me, it’s a matter of being in control of my own body. If I had pain medication masking what was going on, I wouldn’t feel as though I’d even been important to the birth. I also question the incidence of post-partum depression related to the lack of pain medication. I had post-partum depression (worse with each birth), but I’ve always suffered from depression. I also breastfed my 3 kids for a grand total of 7 years. In other words, pregnancy & childbirth are individual experiences. The analogy about dental work doesn’t cut it because childbirth isn’t an illness.

  8. Enkidu says:

    I’ve also heard the argument that in “tribal communities” women have completely pain-free births. That we in the industrialized world only experience pain because we have been “taught” that childbirth is painful. I’d love to know if there is any acutal evidence to support this claim.

    As for my own experience, I’ve had both a medicated vaginal birth and an emergency c-section. I expected the vaginal birth to be less painful than it was (which was very) since I had the epi in place plenty of time beforehand. For the eC-section, I got a spinal that took almost 30 minutes to numb me, and then about 30 minutes after the operation I was in intense pain despite having been administered enough morphine to “put a grown man to sleep” (the words of my doctor). Apparently, my expectations about pain don’t mean squat when it comes to me actually feeling/ not feeling pain, since I fully expected to drugs to work better than they did. I like to say that I just have a finely tuned sense of pain. :)

  9. Enkidu says:

    jude2004: “The analogy about dental work doesn’t cut it because childbirth isn’t an illness.”

    So only the pain from an illness counts? What are you trying to say?

  10. marciac says:

    AlexisT: Urinary catheters are not standard of care for epidurals. “Wearing off of the epidural” is a common claim of NCB advocates to add fuel to their fire. The wearing off is minimal and doesn’t take that long.

    Alison: I assume you’re being snarky here? :) Yes, I’ve heard the whole “conditioning” thing with pain. “Supposedly” there was less pain/complications in earlier times, biblical times, tribal groups, etc. This has no basis in fact. It’s just propaganda. I also think the whole ‘tribal people have fewer complications, less pain, etc’. is a tad patronizing. Me thinks they would be quite happy with meds if they had any ability/method of getting them! No money, no meds, honey!

    Jude2004: Another NCB gem: Childbirth isn’t an illness, therefore the pain is “different”. That old ditty will never get old. “It’s pain with a purpose!” So what? Setting your hand on a hot stove is “pain with a purpose: Get your freakin’ hand off the stove!” And, it’s not an illness, either. But it still hurts!

    Epinepherine: Home birth isn’t safer than hospital birth. In fact, more statistics are coming out that it’s quite the opposite. Don’t go crazy: You read/heard/were told the NCB mantra of Home birth. There aren’t any recent or reliable studies that support that. AND, there is a HUGE difference between “comfort” and “pain relief”. Comfort is kind words, warm water, back massage, flickering candles, etc. None of those things do anything to relieve pain. And, most of which you can get in a hospital.

    Just in fairness: I used to be a childbirth educator (I call myself a “recovering childbirth educator”), doula, La Leche League Leader, OB nurse, etc. And I used ALL those analogies and more! And I am currently embarrassed and regretful that I led so many couples down that ratty old path.
    Oh, I also had four kids: Two with epis, two without. So I know about which I speak.

  11. megancatgirl says:

    I think it’s patently ridiculous to say that the pain is imaginary or we only feel it because we’ve been duped into thinking we will. Geez, it’s a baby’s head ripping through your vagina.

    Everyone has different experiences and some women feel less pain than others. But let’s not pretend that this process is naturally pain-free.

  12. Robin says:

    Unrelieved pain during labor and post-partum has been shown to increase the risk of development of chronic pain conditions…

    Wow! What kinds of pain conditions? Childbirth related cervical or vaginal pain, or, more body-related pain such as back pain or fibromyalgia?

    Are other types of untreated pain a risk factor for chronic pain or just childbirth?

  13. Shannon says:

    I’m continually astonished at the midwifery-woo message sent to pregnant women: endure pain. Why? We deserve it? We’re not worthy of being mothers unless we’ve endured it?

    The problem with statistics about home birth is that women who end up having to go to the hospital are the ones who had complications, so the end-game numbers will always show a high number of healthy deliveries from home births. They have already eliminated the risk pool. It’s much more realistic to look at numbers of women who ended up going to the hospital due to complications, but who originally INTENDED to have a home birth. that’s where the reality check comes in.

    Having given birth to three children, one without medication I can say that all the babies were fine either way but that Momma was much, much happier with epidural . And what’s wrong with that? Nothing.

  14. Chris says:

    I never got an epidural. Whenever I said I would like one for the first two babies, they would first say I was not dilated enough. When I was dilated enough they would send in the nurse anesthetist who would explain in great detail the procedure and risks. By the time he was done talking, I was too dilated!

    My youngest came too fast, I was barely able to get to the hospital, so no meds for me (I was cleaning up enough messes at home with two little boys, I was not going to deal with any more!)

    My oldest is disabled, he had seizures starting when he was 48 hours old. Some numbnut natural birth nazi claimed it was from the epidural (that I never received). Another anti-milk fool said it was because I drank cow milk (at first he claimed it was because the baby had cow milk, I explained as a newborn he only got breast milk, so the goal posts were moved). Ugh.

  15. WilliamLawrenceUtridge says:

    @AlexisT
    “Or they’ve heard too many stories of epidurals gone wrong. Or they simply are afraid of having needles near their spine unless it’s really necessary.”

    This book seems to be aimed at these very people, who are looking into anecdote and uninformed rather than scientific research.

    @Epinephrine
    I’m thinking my wife would be more comfortable in a hospital, since if anything really bad goes wrong there are doctors there. Even low-risk births can still go very badly wrong.

    @Chris
    Your comment seems to reinforce the argument made in Grant’s book – that epidurals should be discussed and administered early rather than late.

    Ultimately the choice should be made by the patient, but through informed opinion rather than indoctrination.

    Wow, childbirth really does bring out the worst in people – and I’m talking about my own rather bitchy comments here. Interesting book, I plan on reading it. The one-star BIG PHARMA comment really strikes me as absurd. Who do they think should write a book about anaesthesia than an anaesthesiologist? An archeologist perhaps? How about someone from a hunter-gatherer tribe, they’ve got the least possible relationship to “big anaesthesia” so presumably they’re most credible. Right?

  16. S.C. former shruggie says:

    Thanks for this post. I see a lot of this “natural childbirth” ideology, and I’m neither female nor a parent, so I can only imagine the ideological spin really abounds.

  17. Zetetic says:

    Ignoring all scientific data by Uber-Natural childbirthers is definitely a syndrome. They are also anti-vax in a very high percentage.

  18. motolibrarian says:

    I’m really glad to see that an actual medical professional has written a book about pain relief during labor. There is so much garbage on the internet promoting natural childbirth, and very little of it is evidence or science-based. I find much of this movement to be incredibly disingenuous, particularly in regards to the intense pain experienced by most laboring women. I personally felt betrayed after a horribly painful “natural” labor that resulted in a cervical laceration, postpartum hemmorhage, and trip to the operating room. Allow me to say that the manual extraction of clots done without pain relief (undertaken to try to determine the source of the bleeding) may have been worse than the actual delivery. I would’ve given my right arm for pain relief. I was one point away from getting a blood transfusion, and the recovery was very long.

    The other problem with the NCB movement is its advocacy of homebirth with unqualified midwives. There are three classes of midwives in the U.S. The only one that is comparable to those attending homebirths in Europe is the Certified Nurse Midwife. The other two categories, direct-entry midwives and certified professional midwives, have disturbingly low criteria for certification. Some can see as few as 100 births and be licensed by their state. It is not surprising to me that few of them have witnessed a true obstetric emergency prior to independent practice, and when confronted with one, they don’t know what to do. This leads to dead and damaged babies, but there is no accountability built into this system. If the NCB community really wants to improve outcomes for homebirth, they need to do the following: make the CNM the only credential for midwifery; carry malpractice insurance; have strict protocol for determining which women are actually low-risk, and transfer care when women no longer fit these critieria; have professional relationships with backup OBs and hospitals; have a dedicated plan for transferring patients during emergencies. Until that happens, I would never be comfortable advocating for homebirth.

  19. MOI says:

    The theme of the book and Dr. Hall’s review appear to be “how dare anyone deny these drugs to women”. Who is denying these drugs to women? According to this…http://www.expectantmothersguide.com/library/chicago/epidurial.htm…70% of women chose an epidural. I chose one with my first and begged for one with my second but my son came too quickly to administer any drugs (it’s kind of an amusing story if anyone wants to hear it).

    When a woman feels pain during birth, the brain releases endorphins that can actually help her fetus deal with the pain of childbirth. With an epidural, the brain doesn’t release those chemicals. For some women, this is enough to forgo the epidural. It’s not about martyrdom, but it’s for some, it’s about doing what they feel is best for their child.

    Where are the data that suggest that an epidural actually speeds up labor? Help me out with this… http://www.ncbi.nlm.nih.gov/pubmed/20224384.
    “Compared with parenteral opioids, neuraxial analgesia does not increase the incidence of cesarean section, although it is associated with a longer (approximately 16 min) second stage of labor. The incidence of operative vaginal delivery is higher in the epidural group but this may be due to indirect reasons such as changes in physician behavior. There was no difference in labor outcome when CSE was compared with low-concentration epidural analgesia, but higher concentrations may prolong labor. Early administration of neuraxial analgesia does not increase the incidence of operative delivery or prolong labor.”

    It seems to take a bit longer to squeeze out your little one. There is a greater chance of “operative vaginal delivery” but they don’t want to blame the epi on this but on physician behavior. But then it states that high concentrations of the drug may prolong labor (are they talking about the 2nd stage??). But then it states that an epi does not increase “operative” delivery or prolong labor….This seems to contradict what was stated. Please, I really need help with this.

    Does epi use increase the use of pitocin? I received pit with my daughter. I was given an epi, a few hours later I wasn’t “progressing” enough for them and was given pit. A half hour later I had my daughter. The nurse joked that it probably wasn’t even the pit that got me dilated. They referred to a “whiff of pit” being enough to speed up labor.

    I have read that a “walking epi” is common in Europe but not in the US. Many women hate the thought of being confined to a bed, not being able to feel their legs while in labor. It didn’t bother me but I think a walking epidural would have been nice. This would also allow women to give birth in various positions, instead of being forced to give birth on their backs.

    I’m due with #3 in just a month. I’m going to try it natural (again) but I will be armed with information on how to better deal with the pain. Now, with my son it was nice being able to walk around, try various movements to deal with the pain and, quite frankly, feeling the urge to push and being totally “with it” while giving birth was surreal. After I pushed my son out (one push!), the pain disappeared and even during the short moments when he was coming, the pain was secondary. I was very much “in the zone” while pushing him out. I’m not suggesting that all women will experience what I did and I don’t fully except this with #3 but for ME, being able to move around, deliver how I want to (on my hands and knees with my son), and not risking the side-effects of an epi (with my daughter I had no side-effects although I didn’t have the urge to push and had to be told when to push) is enough for me to try a natural birth again (and by choice this time).

  20. spalfram says:

    Great post – I’m going to show it to my pregnant sister in law, who feels that she wants to “succeed” with her 3rd birth by not having an epidural. Heck, I might even buy her the book!

  21. LnC says:

    I don’t believe everyone should have an unmedicated birth, but I don’t believe my reason for preferring not to have an epidural fits in any of your categories. I have very fast, fairly easy labors, and I find that doing the work of labor is easier for me if the muscles I’m using aren’t numb. The birth where I had an epidural, I had a lot of trouble figuring out how and when to push. When I could feel the contractions, it was much easier for me to push effectively. I could imagine that for another woman with a longer labor, her experience might be the exact opposite of mine, but that doesn’t invalidate my experience.

    The fundamental difference between dental work and childbirth is that when I have dental work done, I am not expected to use the muscles that are numbed during the procedure, while in childbirth I need to use them.

    I am not arguing that anyone else should or should not have an epidural, just pointing out that there can be rational reasons to opt out of the epidural. Different women can have radically different birth experiences, and there isn’t one answer that is best for everyone.

  22. Bogeymama says:

    Great post! I had my last baby over 8 years ago, and thought the pressure for natural birth was bad back then, but I see it has worsened. To me, it was always about the safety of my babies – I would accept whatever the OB thought was necessary in order to get my babies out the safest way. I happily accepted epidurals, as much as for my husband’s comfort as my own (he had a hard time seeing me in such pain). The first one possibly contributed to prolonged pushing (2+ hours) due to my inability to feel the pushing, but it turned out he was sunny-side-up so he wasn’t coming out with my pushing anyways. The 2nd wore off long before the pushing started, so I got to experience the pain anways. She also took 2+ hours of pushing because OF COURSE she was sunny-side-up too. So epidural or not, my birth experiences were not that much fun, and post-partum recovery was complicated. Not because of the epidurals, but because of their positions. But I didn’t care. They had arrived, and they were healthy. I was happy.

    I have a hard time understanding women’s need to have the birth experience be all about them. It’s the same thing with weddings …. it’s ONE day in an entire lifetime. Too much pressure is placed on women, with the potential to cause post-partum trauma if things don’t go according to the perfect plan, not to mention the potential harm to the baby.

    I recently saw Knocked Up – had to laugh at the scene where she gets a doctor she doesn’t like at delivery, declines an intervention because it’s not part of her birth plan and the doctor gets mad because she’s telling him how to do his job – which is to get the baby out safely. He didn’t have the best bedside manner, but in an otherwise over-the-top comedy, that part of the movie seemed a litle more real.

  23. Epinephrine says:

    @Shannon:

    The problem with statistics about home birth is that women who end up having to go to the hospital are the ones who had complications, so the end-game numbers will always show a high number of healthy deliveries from home births. They have already eliminated the risk pool. It’s much more realistic to look at numbers of women who ended up going to the hospital due to complications, but who originally INTENDED to have a home birth. that’s where the reality check comes in.

    Researchers aren’t blind to this fact; it’s mentioned in many articles. The best studies will match home births to low-risk pregnancies. That’s about all you can do – control the variables that you can control, and record as much detail as you can.

  24. MOI says:

    What studies were looked at where Dr. Grant concluded:

    Unrelieved pain during labor and post-partum has been shown to

    * Cause stress responses that can reduce the baby’s oxygen supply
    * Increase the risk of post-partum depression and post-traumatic stress disorder (PTSD)
    * Interfere with breast-feeding
    * Increase the risk of development of chronic pain conditions

    What about a woman feeling pain herself would decrease the child’s oxygen supply and how was this determined?

    Of the women that developed PPD and PTSD, what circumstances lead to those disorders and what did lack of pain relief have to do with it? How did those women labor?

    I’m particularly interested in the BF claim.

    Someone else had mentioned the forth point.

  25. Scott says:

    Matching home births to low-risk pregnancies is actually addressing another confounder; namely that high-risk pregnancies aren’t generally attempted at home in the first place.

    For Shannon’s objection the proper correction is an intent analysis – if the mother intended/tried to have a home birth, but ended up at the hospital, classify it as a home birth.

    Both important confounders, both need to be dealt with, researchers ought to be aware of and handle both but that’s not always done right (or at all).

    The theme of the book and Dr. Hall’s review appear to be “how dare anyone deny these drugs to women”. Who is denying these drugs to women?

    As I read it, it’s not about “denying” the drugs, but rather telling women they shouldn’t accept the drugs, and making bad arguments to support that position.

  26. eschatologist says:

    The “natural childbirth” movement has in common with other woo that it essentially lays all responsibility for poor outcomes at the patient’s feet.

    If you have a chronic disease, it’s because you don’t eat the right way, don’t meditate enough, poison your body with toxic pharmaceuticals, etc.

    If you have a painful childbirth, it’s because you didn’t mentally prepare yourself, aren’t in the right state of mind, etc.

    It’s a dogma that’s sold as empowering the patient to take responsibility for their health, but in fact blames them for every health problem.

  27. MOI says:

    Scott – What about this…If a homebirth was attempted but the woman had to be transported to the hospital but the outcome was positive, does that count against the safety of homebirth? It is my understanding that most midwives come with medications to deal with situations in which the medications are necessary. A homebirth doesn’t mean a completely untended to birth. If part of the precautions is being sure that you have reliable transportation to a hospital, wouldn’t that be just another “tool” that may have to be used when trying a homebirth? At what point would a homebirth not be “worth it”? A 20% “failure” rate, 5%, 51%?

    I feel very comfortable in a hospital. My doctor and the hospital respect my wishes. They are “progressive” in the simple fact that I am allowed to labor how I wish. An IV isn’t standard (although I don’t have a problem with getting a hemlock), they even provide birthing balls, EFM isn’t constant, only intermittent, vaginal exams aren’t done unless there is an indication for one, and if I wish, I can give birth in whatever position I wish and I’m not told I have to “wait to push” (Oh, I could have kissed that nurse!). My child is laid upon my chest immediately after birth, if I don’t want the cord cut right away, it won’t be…I have talked to many women who either don’t know that they have a choice in these things, they don’t know why they should be given a choice and some feel that because of the environment, they DIDN’T have a choice in any of those things. They end up with a birth they find traumatic and then people scratch their heads wondering why they are “selfish” enough to “risk” a homebirth.

  28. Epinephrine says:

    Thanks Scott; I forgot to address that in my response, and had already hit submit.

    I agree that both are important confounders, and good studies address both. For example, the 2009 study of midwife assisted births in Ontario both matched the women with respect to risk and parity, and looked at planned birth location.

    Hutton EK, Reitsma AH, & Kaufman K. (2009). Outcomes Associated with Planned Home and Planned Hospital Births in Low-Risk Women Attended by Midwives in Ontario, Canada, 2003-2006: A Retrospective Cohort Study. Birth, 36(3), 180-189.

  29. BKsea says:

    To tread perhaps a bit on the religious argument, one thing to consider is that human childbirth is an example where evolution has come up with a rather lousy “design.” Use of epidurals is an example of humans using our big brains to overcome this lousy design given to us by nature.

  30. AlexisT says:

    MOI: The “walking epidural” IS administered in the US; it’s one term for a low dose epidural technique. The issue is, it’s a misnomer. I had an consultant anesthetist on the NHS tell me (when I asked about one) “We do them. No one walks. Your legs turn to jelly.” (To be fair, I do know an L&D nurse who says she’s had epidural patients walk… supported.) US hospitals also have liability to consider. It’s also very difficult to walk hooked up to an IV pole, catheter, and EFM.

    This is anecdata but I know more than a few women whose labors were sped up by epidural: it allowed them to relax and complete dilation.

    I have to disagree with ACOG on one point: We DO let patients go without pain relief in other contexts if it’s their idea. I know someone who doesn’t get novocaine at the dentist.

    Scott, I have heard from natural birth advocates who do think epidurals should be denied. There are still some midwives (outside the US, mostly) who will delay getting the anesthetist or say “you’re doing wonderfully! You don’t need it!” when you’re screaming for the epi. There was even a report in the UK where the NCT and various medical personnel tried to set a target for “normal” birth (they did not explain how this could be achieved if more women wanted epidurals than the target called for).

  31. SF Mom and Scientist says:

    When I have heard people talk about the positive outcomes of homebirth, they always include that you are less likely to get an epidural. I never understood why an epidural by itself was considered a negative outcome.

    I also never understood why the “natural” birth movement is sometimes presented as a feminist movement. What is so feminist about going through pain that could be relieved?

  32. cellculturequeen says:

    Question to the experts: Is there any kind of labor pain relief that doesn’t involve an IV, and if not, is it possible to hold an IV needle in place without adhesive tape?
    The allergic reactions I get from the tape (yes, even the white stuff, though no doctor seems to believe it) are so bad and long-lasting that I would probably risk severe pain to avoid them.

  33. tanha says:

    “a rite of passage that is empowering and somehow enhances women’s worth. Women who “fail” and require pain relief or C-section are often looked down upon and made to feel guilty or at least somehow less worthy”

    Harriet, great post! I personally experienced a lot of sadness and apologies when my “natural” child birth in a hospital turned into a nearly catastrophic emergency quickly resulting in a life saving c-section. Very happy with my outcome but I didn’t appreciate the comments I received from my home birth friends; namely “Oh I guess you’ll never really know what it means to be a strong woman.” WTF?

    What do you think of adding a fourth category:
    4. Women who don’t believe childbirth is painful (just waves of pressure as in the orgasmic birth movement) — I suppose that could be another justification for declining pain meds.

  34. Calli Arcale says:

    Novocain is a potentially dangerous drug, but can you imagine a dentist telling a male patient to “man up” and have a root canal procedure without any anesthetic?

    Tangential, but that is precisely what a nurse in Minnesota recently told a man getting a kidney stone removed. She’d swiped three quarters of his pain meds and injected it into herself. (Yes, she’s in trouble now.) *shudders*

    I am in favor of adequate pain relief, but on the flip side, I do not think that women who prefer to experience the pain need to be demonized either. They’re not all zealots. It’s a corollary to Reason 3 — they may feel the risks outweigh the benefits. Pain is an extremely individual thing, and I’m not sure it’s not legitimate for a person to decide that it’s worth testing their discipline over the medicine. (Then too, there are women who have very rapid childbirth, and for them there simply aren’t any good options for pain relief — unless, as has recently been mooted, we bring back nitrous oxide. It’s not a *great* pain reliever, but it is better than nothing and has the benefit of wearing off quickly once the flow is stopped.)

    I know someone who is so terrified of anesthesia that he has gotten a number of significant procedures done without anesthetics. Is that an irrational reason to avoid anesthesia? Well, a phobia is by definition irrational, but then, if the phobia causes more distress than the pain, it makes more sense to pick the pain.

    I share the anger with childbirth “experts” who say that pain builds character or that women who don’t experience pain aren’t proper women or whatnot. I just don’t want to demonize the ones who have other reasons to avoid the pain relief. At the same time, I do agree that pain relief for laboring women has huge room for improvement.

    BTW, pain during labor is also highly variable. Some labors are much worse than others, and while “pain-free childbirth” is vanishingly rare, some women do experience a low enough level of pain that they are able to tolerate it. I think I’d leave it up to them to decide, and make sure they are aware of the options. And we DEFINITELY need more options for those women who change their mind during labor. I have heard of women who refused pain meds initially change their minds halfway through and be denied on the basis of “I told you so,” and that’s not something that should happen. (I think everybody here would agree with that.)

    BTW, I had an epidural with my first, and it was awesome. I highly recommend it.

  35. AlexisT says:

    cellculturequeen: Yes. Entonox, 50/50 nitrous and air. Commonly used in some other countries (I know of its use in Canada, UK, Australia, NZ and Israel) and being reintroduced at some US hospitals. Some studies showed a miscarriage risk for women who are frequently exposed to it (as nurses/midwives on L&D would be) though this can be minimized–in the UK you need to suck on the mouthpiece to get the gas going. It has a really short duration of action, so you need to keep inhaling. Works really well for some women, is useless for others–anecdotally, I’d say it works best for women who just need a little pain relief. For your long, difficult labor, the epidural is still king.

    Personally, I’d rather have the epidural because I don’t like anything that makes me feel lightheaded/high/loopy. The epi just makes you numb, and I prefer that.

  36. “Childbirth is a subject that seems to bring out the worst in strongly opinionated people.”

    Since I never delivered or gave birth to a baby, and do not foresee a need to do so in the future, I can’t say I have much opinion on the topic. It was an interesting read, which perhaps will help me if a friend tells me that she heard epidurals are dangerous.

    But mostly I just had to say I love the above line and the great thing is that you can substitute a bunch of different topics besides childbirth. :)

  37. Geekoid says:

    I am not likely to ever give birth; however I have strong opinions about this for one important reason: It leads to the naturalistic fallacy. A fallacy that is leveraged to sell people useless crap, and scare them away from life saving modern advances.

    TO my mind we all should have an opinion based on the best current scientific evidence.

    Yes, women should decide, but the should be given the honest facts and this little contest of what constitutes ‘real’ childbirth needs to end.

  38. Margaret says:

    I agree with AlexisT. There are other perfectly good reasons besides religion or heroism for rejecting an epidural. IT is highly individual.

    As someone who had an epidural with the first birth and had an awful experience, there are some good reasons to not get one at least for me First of all the placement of my epidural was absolutely PAINFUL. It felt like I was being stabbed. I have scoliosis and they hit some nerve, I don’t know. I also didn’t like not feeling in control of my body…I felt paralyzed which I hated. And the IV and urinary catheter were no fun either. That lack of control over one’s movements can be disturbing to many people.

    After my first bad experience with an epidural I had no plans to get one the second time around. Honestly, it didn’t feel like bad pain or suffering. I wouldn’t even say it was painful…just uncomfortable, at elast until the last 15 minutes. Some pain relief would have been nice there! And believe me I asked for and received pain relief afterwards. I would say the worst pain was after birth!

    I’m one of many people who just felt an epidural was not worth all of that.

    It is a good pain relief option though, and I totally agree that there are a lot of zealots who look down on women who choose them. THey treat an epidural as the ultimate enemy of birthing women which is absolutely ridiculous. However in my experience it’s a fight to reject an epidural when you don’t want one.

    It’s such an individual decision, it is really up to individuals to evaluate what is or isn’t important to them regarding pain relief and navigating child birth and providers should be willing to support patients either way.

  39. MJM says:

    I am a practicing medical oncologist. The modern recommendations for the treatment of cancer-related pain are to intervene with medication as soon as pain occurs and to escalate the dosage of medication until pain is relieved. This was not always the case, of course. Many years ago patients were allowed to suffer for all sorts of ill-informed and prejudicial reasons. The first long acting opiate was approved in 1987. It has been years since the practice of pain management was integrated into modern oncology care. It cannot imagine what oncology was like before then. Now it is the standard of care. Pain levels are recognized as a vital sign. Pain management and palliative care are now required elements of a medical oncology fellowship. It would be unthinkable to tell a cancer patient in pain that they were a “failure” if they took pain relief. Or that the drugs were “too dangerous.”

    Does this really still go on in obstetrics? On a regular and apparently organized basis? I find that chilling.

  40. Dr Aust says:

    Over here in the UK birth is possibly a tiny bit less politicised than in the US, though we have exactly the same “natural vs intervention” and “home vs hospital” debates, which do get pretty heated, especially on the blogs.

    Mrs Dr Aust used to put in epidurals as a trainee anesthesiologist, and we had one for our first child, but not for the second. We never really felt the contrast was a big thing – it was a question of “what was appropriate in the circumstances”, and we were just pleased to have a healthy baby both times at the end of it. I wrote about this a few years ago here.

    It does seem pretty clear to me that the polarisation of the birth debate is NOT likely to help people make informed choices.

  41. mamabear says:

    They forgot a category of people objecting to epidurals. That would be those that have had them before and did not like it/had side effects they did not like. Epidurals are great for long labor’s and those that want them.

    I have had one that went great! Then I had one that gave me a headache for 2 weeks afterward, and caused a dangerous blood pressure drop. So for my third birth I chose to not have an epidural–it was not a pic-nic, but it was straightforward and did not hurt as much or as long as that headache did.

    Let people make the choices they want to and let’s not demonize anyone for the choices they make in childbirth just because they are not the ones we would make.

  42. MOI says:

    How were the risks of an epi “put into context” and did those risks include complications from the catheter?

    What’s odd when reading this and the comments is what I perceive as a tone that if a woman doesn’t use drug pain relief during birth there is something wrong with her.

    What naturalistic fallacy is displayed within “natural birth advocate” literature? If there is a problem, that problem needs to be tended to and remedied as much as possible. However, if there is no indication of a problem, why introduce interventions?? Perhaps it’s possible that the behaviors women go through during labor and delivery are a result of evolution. Perhaps walking around helps the child get into position for delivery. Perhaps delivering in a position other than the prone position is done because it allows for maximum room to pass the child through and also uses gravity to help expel the child. Our bodies don’t always “know” what to do. But if everything is going alright, why get involved? My body knows how to digest food. I don’t need someone helping me with passing the food through my esophagus, breaking it down via fluids and muscle contractions in my stomach and all the processes involved once it hits my intestines. IF there is a problem with this process, I get help for it, otherwise, I let my body do what it does. To state “I trust that my body knows what it’s doing in terms of digestion” is a naturalistic fallacy is ridiculous.

  43. hokie98 says:

    Okay, so put me in the natural childbirther category. My first child is 5-1/2, and I gave birth to her without pain med. It was a choice I made – to be honest, I wasn’t in much pain initially, and didn’t really see the point in an epi. I’m also not a big fan of needles – I tend to faint when a needle is involved, so the idea of one going in my back wasn’t ideal. Thirdly, sometimes I have adverse reactions to pain meds – they make me sick, so I was also cautious in that regard. Even though I’m a redhead and hear I *should* be more sensitive to pain, I think I have a pretty high tolerance.

    After my labor wasn’t progressing fast enough, I was started on pitocin. Oh yeah, it hurt, but I didn’t find the pain completely unbearable (my labor lasted less than 6 hrs from start to finish – if I was going all night long, I may have a different opinion). My daughter actually came out hand first, so the most painful part was the crowning of the head/arm. I won’t lie – it was exactly like the nurse said it would be – like a ring of fire. However, as soon as my daughter pasted through the birth canal and was born, then I was pain free. I got up soon there after and walked around, without issue.

    I’m actually 5 months pregnant now…I haven’t decided what I’m going to do this time around, but at least I know pain med free is an option.

    Just like breastfeeding, I think it should be up to each woman to decide what is best for her, and others shouldn’t cast judgment either way.

  44. hokie98 says:

    By the way, for the record, I’d like to point out that if my OB hadn’t been in a C-section, I may have gone with an epi at some point, but by the time she got back to authorize it, I was already 10cm and it was go time.

  45. What’s so hard about this topic on the ground is that the most extreme NCB proponents promulgate and facilitate outright bigotry. It’s ugly, damaging, and scientifically unfounded–much like racism. Women’s physiology, pelvic structure, and individual pregnancies fall along a continuum just like skin color. Human diversity is one major factor influencing the way women give birth. Deriding a woman for receiving an epidural is like deriding someone with fair skin for using sunscreen.

  46. watso359 says:

    @ MOI

    I don’t think (hope) anyone here is saying that “that if a woman doesn’t use drug pain relief during birth there is something wrong with her.”

    There is concern that claims about the use of analgesic medications causing complications is being over exaggerated by individuals with a natural ideology.

    Digestion does not cause you a significant amount of pain though does it? If it did, wouldn’t you seek help and relief of the pain? What if you were told that this digestion pain made you a better person and you would be weak to ask your doctor or nurse to control it.

    A more apt comparison might be the natural dying process. Should we forgo narcotics, because it might interfere with the bodies natural process of shutting down, because that would make the person weak for not wanting to face death “sober”.

    Again nobody is saying you need pain relief, but that it should be available if the risks of it’s complications are low.

  47. Amy says:

    On the home birth: epinephrine (?) said “province” home birth is a lot safer in Canada than America because they have properly trained midwives and transport systems for emergencies. Home birth in America isn’t really well studied, nor are there many, but home birth midwives (CPMs) are not highly trained as in certain other countries and as well trained as CNMs in the US (who are, but mostly do hospital births).

    On breastfeeding, is that a longterm effect? I was told it may hinder immediate BF, the nipple may not be erect under an epi, but it seems once it wore off (within an hour or so) this wouldn’t be a problem?

    Having an epi or not is fine, it’s the unscientific claims that are so frustrating. You can expect pain, how severe is unknown, how you handle and manage that is up to you. It’s not a competition, or it shouldn’t be.

  48. Narad says:

    “The dentist doesn’t wait to inject Novocain until you feel the pain and complain.”

    For fillings? Mine always have, although in seeking out this approach I now seem to be in the category of “you and the 90-year-old Japanese guys.”

  49. Samantha says:

    @SF Mom said: I also never understood why the “natural” birth movement is sometimes presented as a feminist movement. What is so feminist about going through pain that could be relieved?

    The way I understand it from my forays into Women’s Studies is this: Medicine has been dominated by the patriarchy; women haven’t had agency to make their own decisions about their health due to doctors, mostly male, dictating what needs to happen. Ergo, birth, by virtue of being one of the few female-only experiences, is being retaken as something that women can do without the medical establishment.

    Or something like that. I’m pretty against the NCB thing myself – too many chances for things to go wrong. But wow, was I condemned in a women’s issues class for that perspective. Don’t even get me started on the breastmilk is bestmilk thing… Hoo, boy.

  50. I was doing a research concerning childbirth in Africa and 90% of the women give birth without any pain relieve therapies. Interesting!!!Right???

  51. …but I am intrigued by another category of rejecters: those who reject pain relief in childbirth. They seem to fall into 3 general categories:
    Religious beliefs
    Heroism
    Objections based on safety

    Where’s your study for that? Your numbers? Because I’d like to see that.

    There are a whole lot of us who ‘rejected’ an epidural because we don’t want or need one. Talk as much as you want about ‘the excruciating agony of childbirth’ but don’t act like that’s the only way birth happens. Some of us didn’t need pain relief, some of us only needed a little. I used Entonox over transition – four hours of posterior labour with no support because no-one believed I was in labour (in spite of the induction and big notes from my ob.) meant I didn’t have enough resources to deal with transition well. Once my partner got there I calmed a bit, once I had a few hits of the Entonox, I was even calmer. It would have been good if it had been working the whole time I’d requested it, but I got an idiot who couldn’t work the machine properly. Once I was through transition, I didn’t need it again.

    Not because I’m religious. Or a hero. Or concerned about the safety. But because I didn’t feel I needed it. People do PLENTY of painful things for the sake of doing those things – marathons, gym routines, plastic surgery, high heels, the list goes on. Pain is not the most horrifying thing that can happen to a body. For me the pain was productive and was not unmanageable. So that’s what I did.

    It’s nothing to do with religion, or heroism. But it’s a lot to do with my own desires and experiences. My idiosyncratic response to anaesthetics far outweighed any real desire for an epidural (except for transition and a midwife telling me I still wasn’t ‘really’ in labour and still had hours and hours to go) and my terrible response to morphine/codeine made pethidine very dicey as well. So I opted for Entonox.

    It’s irritating that both sides are so damn righteous and determined to stick the other side in a box that doesn’t really fit. Yeah, there are jerks out there on both sides (I cop it from the homebirthing friend and the epidural salesman brother-in-law because I didn’t do it according to either script) but that doesn’t mean someone who got no pain relief, or no epidural, fits into those three categories and insisting that’s the case is kinda offensive and irritating.

    As far as feminism and birth goes, a lot of it comes out of the truly godawful way pregnant and birthing women have been treated and because it was such a major cause of mortality for women. If you care about the rights and the health of women, you care about pregnancy and birth as well. But please, put it down to some ridiculous and as far as I can tell, totally made up theory of feminine exclusion.

  52. beatis says:

    When I was pregnant – now nearly 24 years ago – I was told by the most famous midwife in the Netherlands that pain while giving birth is necessary. According to her, a mother can only bond properly with her child when she has experienced substantial pain.

    I was too timid back then to ask any questions, let alone dispute this, but I have always wondered how fathers bond with their children.

  53. lamamaloca says:

    “The way I understand it from my forays into Women’s Studies is this: Medicine has been dominated by the patriarchy; women haven’t had agency to make their own decisions about their health due to doctors, mostly male, dictating what needs to happen.”

    It was women who demanded anesthesia over doctor objections, and women who brought twilight sleep to the US, again despite the male doctors complaining about safety. It isn’t men who “forced” anesthesia on women. Women’s demands have lead to the development of safe pain relief techniques for childbirth.

  54. Dash says:

    I’m irrational and I’ll happily cop to it – no-one’s coming near my spine with a needle if there’s any way I can possibly help it.

    If this analysis is correct, brilliant. It still won’t matter to me, but most people I know who have avoided epidurals it’s been because of concerns about being unable to move, feel contractions or concerns it will lead to more interventions. Most women I know want to make decisions for their baby and their own best health, so good information is important rather than propaganda.

    But how good is this?

    Many safety objections to epidurals are based on outdated information about older techniques. New epidural/spinal techniques use a combination of low-dose anesthetics and narcotics to abolish pain without interfering with muscle function. They do not prolong labor or increase the need for instrument-assisted deliveries, and they allow patients to control the dose and to get up out of bed and walk around.

    This is the part that has me worried. It’s anecdotal sure, but few of the women I know who’ve had epidurals, including in Spain, the UK and Australia, have experienced this. More have had pain, epidurals wearing off (during a caesar), interventions and being unable to walk, sometimes not until the next day. So where are these modern epidurals that avoid these problems available? Because if they aren’t, isn’t this a bit like telling African women that formula is fine based on US conditions?

  55. Scott says:

    Scott – What about this…If a homebirth was attempted but the woman had to be transported to the hospital but the outcome was positive, does that count against the safety of homebirth?

    Depends why the transportation took place. “Positive” vs. “negative” outcomes is too broad a brush. What you really want to do is count complications, record how long it took, etc. If the transportation to the hospital was necessary because of excessive bleeding, it counts as a case of excessive bleeding for homebirth (for example). If it was just a case of the mother changing her mind halfway through labor, it should probably be excluded from the analysis as uninterpretable.

  56. Epinephrine says:

    @Amy:
    You said

    On the home birth: epinephrine (?) said “province” home birth is a lot safer in Canada than America because they have properly trained midwives and transport systems for emergencies. Home birth in America isn’t really well studied, nor are there many, but home birth midwives (CPMs) are not highly trained as in certain other countries and as well trained as CNMs in the US (who are, but mostly do hospital births).

    I think you’ve misunderstood my example; I spoke about my province, as the study I was referring to was for my province. It compared homebirth in Ontario to hospital birth in Ontario, both midwife attended. It doesn’t address Canada/US comparisons, nor does it look at epidurals, save that there are differences in the number of epidurals given to the women in the study, as the home birth cohort who have home births will certainly not have them. My initial point was that comfort is important; there are many reasons why my wife didn’t want a hospital birth, and why she didn’t want an epidural – and that from a safety perspective, she was as safe at home as she would have been in the hospital, and was actually less likely to have various complications. It’s also a good example of a study that controls for some confounds.

    The OP points out that newer epidurals are better – but where are they available; are they everywhere? Does practitioner skill matter? Using statistics from your local hospital may be much better than referring to a study in which different epidurals are compared. As a patient you don’t always get a choice of treatment; my daughter’s club foot surgery was presented as the solution that was available; we were never told of other options (e.g., Ponseti method, or botulinum), as the surgeon we had was trained in tendon release. Similarly, most women won’t have an option as to what type of epidural they are given – you’ll get whatever your anaesthesiologist is comfortable offering.

    Now, I’m not sure what to make of the claims cited in the OP; for example, I have the chapter on Effects of Epidural Analgesia on Labor and the Infant from the text Obstetric Anesthesia Handbook, 5th ed. (S. Datta et al., 2010) in front of me, and it contradicts some of these claims. For example, it points out that instrumental vaginal delivery (forceps, vacuum) is approximately doubled with an epidural. It could be that it is wrong, but it’s a pretty credible source, and the study it cites isn’t that old, though the data for the meta-analysis may be older, I haven’t followed up on it. The authors’ conclusion is that epidural analgesia remains the best choice for pain relief (compared to systemic opioids, for example), but that “even properly conducted epidural analgesia can potentially have adverse effects on the process of labor and delivery and on the condition of the neonate.”

    Believe it or not, I’m not anti-intervention, nor am I a believer in any “natural fallacy” – I do wonder about the claims made, given that they are at odds with what I have read, and I think that failure to acknowledge that epidurals come coupled with a hospital environment (and all that accompanies it) is short sighted; birth is a complex process and there is more to comfort than pain relief and numbness.

  57. MOI says:

    Watso – I suppose I was just stating that having a hands off approach to labor and delivery seems like common sense because it is what (most) women are “designed” to do. But, yes, if the woman is asking for pain relief, it should be available and we should do all we can to make sure it’s safe. We’ve come a long way since filling up the woman with powerful narcotics and essentially ignoring what the effects were on the infant.

    Scott – Yes, the reasons for why the transport to the hospital should be included otherwise you don’t get the “full” picture. Thank you for your response.

    Perhaps I’m just reading the wrong material, but I don’t see the NBC as “extreme” or “dogmatic” and I can’t help but think “strawman” when I read some of these comments (I also don’t equate it with the HBC). Those who have studied birth throughout the years and have witnessed low/no interventions during labor and delivery can actually teach us something. How many think that arriving at the hospital, laying down, being hooked up to monitors and then being told when to push is the norm? I know I did until I started to read NBC literature.

    I highly recommend the book “Deliver Me From Pain” by Jacqueline H Wolf. It’s a fascinating look into the past 150 years of childbirth and the evolution of the OB profession. Women absolutely asked for pain relief but they were asking out of ignorance. For example, when ether was being used during doctor lead homebirths, it was used when the child was crowning (the doctors, all male at the time, assumed that is when birth was most painful). The women assumed that they have been saved from the most painful part of labor, were grateful and told their friends. What they didn’t know is that it’s very likely they had gotten through their most painful part of labor (transition) and didn’t really need the ether for delivery. At this time too, there wasn’t much support besides having the doctor there for labor and delivery. It has been noted throughout the past 150 years that the more support a woman has during the birthing process, the better off she is in terms of comfort.

    The OB community was often split on whether or not various forms of pain relief should be used. Some doctors lauded it, others loathed it. The ones who lauded it saw childbirth as almost barbaric, something in which the woman needed to be saved from. It wasn’t until Dr. Apgar (I believe she was a doctor) came up with her scoring system that a systematic way of assessing the newborn was used and the various forms of pain relief could be properly reviewed in terms of how it affected the infant. If I remember correctly, Apgar scores weren’t used until the 60′s.

    Feminism started to play a role in the 70′s…Childbirth was sold as practically painless. This backfired as women soon learned that it wasn’t. But one must remember that women were discouraging others from pain relief in hospital settings. You were still told to lie down, sit still and not to push until the doctor said it was OK. If you are going to ask women to forgo pain relief, you also need to arm her with knowledge on how to deal with the pain. The feminism centered approach to childbirth also lost a lot of steam when women started to become OBs themselves, they went through the process of giving birth, had pain relief and then recommended it to their patients. But again, these women gave birth in hospital settings, laying down, not moving much and being told when they can push.

  58. etidwell says:

    As someone who had 2 drug-free labors, I honestly couldn’t care less if you did, too, or not. But I think this post glosses over some important issues and makes some false assumptions.

    First, the 3 reasons stated above for going meds-free don’t cover all women. I went mostly meds-free for both my kids’ births. Though for the sake of argument, the second hardly counts as a decision because I was in labor only 90 minutes and wouldn’t have had time for medication anyhow. With my first, I went med-free because (A) it didn’t make sense that I was supposed to spend 9 months avoiding medication to keep my baby safe, then let someone shoot me up with IV drugs at the last minute; (B) I am terrified of needles, especially big-ass needles that go into my spine. I’m sure my brain would’ve notified me had my pain been bad enough to overcome my needle-in-the-spine phobia. If YOU want to sign up for the big needle, hey, more power to you.

    Second, one book is not a definitive statement on the safety of drugs. Just because Dr Sears wrote a book about vaccinations that’s kinda anti-vac, should we conclude that vaccines are definitively not safe? Of course not. If you already have a drum to beat, I’m sure you can read it that way, but that’s not really “good science”.

    Third, this post ignores the fact that non-epidural drugs are available to laboring women, and that the choice to go drug-free may not be about epidurals specifically, but about the effects of numbness on a woman’s ability to move about or position herself in a natural way that assists her body. Ignoring these other considerations ignores the actual complexity of the drugs-or-not issue.

    In conclusion, I personally would much rather someone go invent an awesome anti-nausea or anti-heartburn medication that really worked in pregnancy. The few hours of pain involved in labor paled in comparison to the combined 18 months of my life spent being nauseous 24 hours a day. I would do labor again anytime, but thanks mostly to “morning sickness”, I hope to never, ever be pregnant again.

  59. openeyes says:

    As a kid I didn’t like needles, so when I went to a dentist for a filling I’d just focus on my breathing and it was always okay. Even now as an adult, when I go to the dentist they simply tell me to let them know if/when it hurts too much, and it never has. In fact it’s typically pretty mild. My dentist says she wishes all her patients were so easy. I once decided to let them give me novocaine to see how the experience compared, and I greatly prefer the experience of not using it. Once they’re done I can go off and do whatever I want, with no numbness.

    I imagine a lot of people could handle a regular filling without novocaine, but they’ve always been taught they need it, likely have a bit of fear built up around dentists, and have not been given any training on how to deal with pain if/when they feel any.

    With pregnancy there can be a lot of similarities in that regard. In 1944, Grantley Dick-Read, MD wrote “Childbirth Without Fear”, focusing on the idea that a lot of the pain experienced in normal childbirth is due to the fear surrounding it and lack of training. Now people are writing books like “Orgasmic Birth: Your Guide to a Safe, Satisfying, and Pleasurable Birth Experience”. Sounds good to me.

  60. watso359 says:

    Openeyes

    Most people cannot tolerate having a tooth drilled without pain control.

    http://www.sciencemag.org/content/288/5464/306.abstract

    Pain is much more complex than just fear.

    Maybe you have genetic variation involving neural processing.

  61. LnC says:

    I haven’t read the book, but it bothers me that the Dr. Hall’s post leaves no room for a patient having legitimate issues with either the experience of having an epi or the process of getting one. Giving birth is fundamentally different from dental work. If I’m having a tooth pulled, all I need to do is lie there while my dentist removes it. When I give birth, I need to push the baby out. I find it easier to do that when I am not numb. The fact that epidurals remove all feeling is a downside for me. Perhaps some hospitals offer epidurals that are less deadening, but I didn’t have an infinite choice, I had to take or leave what my hospital offered.

    Also, when I gave birth to my first child and did have an epidural, it was very very expensive. I gave birth at a hospital that participated with my insurance, but the anesthesiologist on call did not participate and I had to pay “out of network” rates. The memory of that bill certainly influenced me to try for an unmedicated birth with my next child. If the anesthesiology community is actually concerned about increasing the percentage of women who receive pain relief, I would suggest they start by encouraging their members to participate with major medical insurance plans.

    If 30% of all laboring women are turning down pain relief, it seems to me that the medical profession should be looking at what they can do to address legitimate complaints, instead of assuming that we are ignorant or irrational.

    1. Harriet Hall says:

      LnC said “I haven’t read the book, but it bothers me that the Dr. Hall’s post leaves no room for a patient having legitimate issues with either the experience of having an epi or the process of getting one.”

      If you had read the book before commenting, you would have realized that it specifically addresses the pushing issue. If you had read my post more carefully, you would have realized that it addressed two separate issues: rejection of pain relief in general, and rejection of epidurals because of misinformation and ideology. I said “I support the right of women to reject pain relief on the autonomy principle.” which of course means I also support the right of women to reject epidurals or any other method of pain relief.

  62. Amy says:

    @ beatis: so true! That claim is one of the most offensive, not just to dads, but adoptive parents.

    @ epinephrine: I left out a period, which messed up my quote. Should be a period after “province.” and then me saying HB in Canada is safer than the US.

    @ Lnc: the problem some women have is they listen (and believe) biased NCB unscientific claims about the epidural (and childbirth), and go in scared of the epi and thinking the pain will be easily managed. Then, find out it’s quite painful and upset because it didn’t have to be painful at all. There are legitimate concerns about the epi, and they should be explained. The problem is spreading lies to convince women into one’s ideological position. I wouldn’t say childbirth is the most horrendous pain you’ll ever experience (when I have no clue what that will be for you) and epidurals are 100% safe (when they aren’t) because I had a great laboring experience with the epi (with no personal negative side effects). It seems far too common to hear the opposite of this from NCB advocates (and forums), and possibly worse, when they won’t accept anything positive about the epi.

    Also, on the numbness, many women still feel the urge to push with the epi.

  63. beatis “According to her, a mother can only bond properly with her child when she has experienced substantial pain.

    I was too timid back then to ask any questions, let alone dispute this, but I have always wondered how fathers bond with their children.”

    I’ve heard a few reports about oxytocin as it relates to parenting. Here’s one. “Levels of the nonapeptide oxytocin, which has been associated with parent-infant bonding in several animal studies, also increase over time for new human parents — with no significant differences in the levels found between mothers and fathers, according to a new prospective, longitudinal study.

    These results “are the first to describe plasma [oxytocin] levels in new fathers and mothers across the transition to parenthood in relation to…typical parenting behaviors,” investigators write.

    “These data may provide a normative basis for the study of parenting under conditions of high risk,” they add.

    In addition, although oxytocin “has typically been considered a maternal hormone associated with birth and lactation,” other aspects of parenthood appear to stimulate oxytocin release in fathers, report the study authors.

    This finding “emphasizes the importance of providing opportunities for father-infant interactions immediately after childbirth in order to trigger the neuro-hormonal system that underlies bond formation in humans,” said corresponding author Ruth Feldman, PhD, from Bar-Ilan University, Ramat-Gan, Israel, in a release.

    http://www.medscape.com/viewarticle/727506

    sorry for the length

    I also once heard a report (on NPR?) regarding oxytocin levels in non-maternal “helper” female rats. It appears that females rats that have not given birth, will help care for the young of another female. They had similar levels of oxytocin to that of the mothers. The report seemed to suggest that the females proximity to the pups triggered the release of oxytocin.

    But, damn I could not find that research to link too.

  64. Artour says:

    Russian MDs practicing the Buteyko breathing therapy have found that when pregnant females have very slow breathing rate at rest (only about 3-5 breaths/min), they naturally have painless childbirth.
    Learning the original Buteyko method is a tough challenge that requires 1-2 hours of daily breath work (similar to pranayama to raise body CO2), hours of physical exercise with nose breathing only, and many other activities to slow down the repsiratory pattern.
    How could it work in case of painless childbirth? CO2 is a powerful relaxant of muscle cells and can prevent or eliminate spasms (one can try a very long breath hold and reduced breathing to see its effects on constipation). In addition, very slow breathing improves oxygen transport due to vasodilative and Bohr effect-related effects of CO2.
    This web page (Buteyko Table of Health Zones) provides more info about some unusual abilities, apart from childbirth, of humans when they have very slow breathing rates:
    http://www.normalbreathing.com/index-buteyko-table-of-health-zones.php

  65. Regina Phalange says:

    The idea that those are the 3 main reasons is not reality based. It looks like the thoughts of an outsider not in touch with the natural birth community.

    The percentage of mothers that have religious objection to epidurals is very low.

    The idea that they do it for heroism is just silly. Yes, women feel empowered afterwards but that’s not WHY they do it.

    Natural birth advocates tend to be well versed on the risks (there are risks to everything) but that doesn’t mean they don’t get the epidural because of the risks. The risks are low and epidurals are generally very safe. We know that.

    I chose an epidural for my first birth and the experience was fine. No complications, baby born vaginally and all was well. But I was left feeling like there had to be a better way. I did not like being numb and in bed for birth. And yes, it DID have to wear off. I have this brand new baby and I can’t even move my legs to get comfortable with holding him and positioning myself better for establishing breastfeeding. The birth felt like a passive experience for me where someone delivered him from me rather than me giving birth to him.

    I personally have no desire to suffer through childbirth so I decided to look into natural options in my next pregnancy. That’s when I really connected with the natural birth community. I figured I’d give it a go and if it was still painful I’d get the epidural again, no harm done. Turns out, my natural birth education led to a nearly pain free natural birth and I never even thought about getting the epidural. I simply didn’t need it. The labor was very long but totally manageable. Baby was 9.6lbs with a 15″ head and had a tight double nuchal cord. I pushed him out on my hands and knees and he wasn’t descending in any other position. There’s a good chance he would have ended up born by c-section had I not been able to do so.

    Actually, my epidural birth was more painful than my natural birth.

    So then I had a third and chose to go natural for that one as well. Baby was also 9.6lbs with a 15″ head but this time had a nuchal arm making it even larger to pass. I was kneeling as I pushed his head out into my own hands. No one else’s hands were around as my Midwife did not interfere. My body instinctively switched from kneeling to hands/knees as his body was trying to come out (he had a very large chest). It’s amazing what our bodies will do! I had no tears and it felt almost like I had never given birth immediately after. My best recover by far.

    Personally, I much preferred taking a more active role in my own births. I liked feeling my contractions and feeling my baby descend. It wasn’t a torturous experience. I find that most of my natural birth friends feel the same way — the desire is to avoid a passive role in birth.

    There’s nothing wrong with epidurals for those who choose them. And there’s nothing wrong with natural births for those who choose them.

  66. Regina Phalange says:

    Oh and as an active member of m local birth community, I can assure you that there are NO hospitals in my area who give epidurals that allow women to get up and walk around. That is not an option in my highly populated area of 7 seven large cities.

  67. beatis says:

    @micheleinmichigan

    Thanks very much for this info!

    I remember my grandmother having a cat and a dog, a german shepherd. The dog was a male and the cat and the dog were great friends. The dog was present when the cat had a litter and he looked after the kittens as much as the mum, he did things like licking them after nursing, herding them when they ventured outside and bringing them back in his mouth to their mum when they had wondered off too far. He also let them cuddle up to him to sleep and was very careful not to hurt them. Perhaps this was all “just” his herding instinct, but it did look as though he had really bonded with the kittens.

  68. Werdna says:

    “There is value in comfort and feeling secure, especially when it comes with a lower risk of complications, despite feeling more pain. ”

    I’ll assume you are pointing to the 2009 CMAJ study: “Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician” but you know it’s way better if you actually cite things rather than just allude to a recent study.

    Anyway you’re making an incorrect conclusion about relative risk.

  69. micheleinmichigan on her grandmother’s GSD: “It did look as though he had really bonded with the kittens.”

    Well, yes, obviously. He hadn’t had an epidural!

  70. Ahem. Trying again.

    *** *** ***

    beatis on her grandmother’s GSD: “It did look as though he had really bonded with the kittens.”

    Well, yes, obviously. He hadn’t had an epidural!

  71. beatis says:

    O shoot, of course, how stupid of me!
    :-)

  72. MI Dawn says:

    Well, as a coward of the first degree, I refused epidurals with both my childbirths and other gyn surgeries. While I am fully aware that an epidural goes nowhere near the spinal cord, I can’t convince my gut of that. The thought of an epidural scares me enough to qualify as a phobia. So, no epidurals. (Yes, it’s an unreasonable fear. Yes, I know it makes no sense. It’s just the way I am.)

  73. watso359 says:

    @Artour
    You want to increase tissue O2 perfusion by inducing hypoxia?

    Low CO2 increases increase nociception; you would need to induce hypercapnia to levels of unconsciousness to abolish nocicepetion as you describe.

    You = Logic fail.

  74. laural77 says:

    I am glad this book was written. It is timely and needed- women should not, not, not feel guilty about choosing to have an epidural. From what I can tell, many women do have a good deal of guilt over it. I hate overhearing someone tell their birth story when they are compelled to ‘explain’ why they just had to have an epidural- not all women have guilt over it, but many do, and I sure hope this book helps free women from that unnecessary burden!

    Moreover, would that all epidurals would be so conscientiously administered- how wonderful, to be able to have mobility, and even to have pain relief for afterpains! It is an enlightened, modern approach and I hope it helps educate professionals as to what the standard of care should be in pain relief with epidural anesthesia, as well as frees women from feelings of guilt and inadequacy. Pain relief in this day and age should be nothing less than the ideal described by Dr. Grant, period. I applaud him. I think pain relief should be better not just in laboring women, but all specialties- in this day and age there is no excuse to let people needlessly suffer.

    Dr. Hall, on another note, while I appreciate your post, I have to tell you your words about those of us who do not choose to have epidurals fitting in those categories you mentioned- well, it makes me feel like I must be some kind of zealot or freak. The nurses at the hospital made me feel that way, too. Since I read the post this morning I have been pondering my aversion to narcotics during labor or getting an epidural like I need to have some rational explanation to support this choice or resign myself to one of your categories; which I sincerely don’t relate to- I don’t feel like a ‘hero’, don’t get the religious rationale at all, and, while I did think there were medical risks with an epidural I was not against getting one if needed. Autonomy and control- not being relegated to that hospital bed on my back were important to me; but I don’t know if that rationally ‘justifies’ all my hard, painful work- it is almost more like I am my toddler who just wants to do everything by herself despite well intentioned adults who want to help her. I always told my ob and midwives I might want an epidural at some point. I am sort of anti ‘birth plan’ for myself- you never know how labor is going to go. I have had three unmedicated births, two at a hospital, (my middle child was at a birthing center with CNM’s), and both times at the hospital was made to feel like I was some hippie zealot (by the nurses, not my OB or CNM). I am not. In a risk free world I would give birth by myself in a locked bathroom because I find it rather a private thing and am profoundly embarrassed to have all that loud messy business in front of all these strangers. Of course I would never give birth in the bathroom on purpose because I want more than anything else to have a healthy baby and to do what is best for that baby, and that means being in a hospital or birthing center close to a hospital.

    Was it Amy Tuteur in this blog who said she liked the “Burger King” approach to birth, ‘have it your way’? I love that. In fact that is my hope for care during labor; that it can be, truly and safely, the experience the woman wants, without judgment, with full and kind support from all those present. Giving birth is something one always remembers, and it is worth the effort by all involved to have it be a blessed and joyful experience that is nonjudgmental and free from guilt.

  75. Harriet Hall says:

    @laural77

    My 3 reasons were meant to apply only to those who categorically reject all pain relief, not to people like you. I made it clear that I have no objection to “Burger King” choice as long as it is based on informed consent with accurate information.

  76. birthherstorian says:

    You guys are clueless and your “science” vacuums, too.

    “Let us bring them into harsh rooms with bright lights. Let us make them lie on their backs on hard narrow beds. Let us tether them to machines so they cannot move. Let us make them stay silent and make no noise with their pain. Let us expose their most private parts and threaten them with cold steel. Let us make them push their babies upwards, against the pull of the earth…In these conditions, labour swiftly becomes unbearable and pain relief becomes a woman’s only hope… This is not the natural cry of a woman in labour bringing a child to birth, although if you have only ever witnessed childbirth in a medicalized setting you might be forgiven for thinking so. This is the screaming plea of a tethered animal in pain. “

  77. DJ Lane says:

    I don’t have a dog in this fight either, except to say that as woman who had four midwife-assisted home births, having an epidural myself was not an option.

    I have never been a person who pushed myself physically through athletics or other means. I also have a low pain threshold, and I use pain relief for dental work, etc. However, I believed strongly that birth was a natural physiological process, and it was important to me to experience that process without pathologizing or medicalizing it. I had healthy pregnancies. I received appropriate pre-natal care, was low-risk for complications, and had a midwife with appropriate back-up assistance to provide help if anything abnormal happened.

    I only experienced pain to the point where I might’ve considered having an epidural during my first labor; however, it never occurred to me to go to the hospital for pain relief. I find this hard to explain to those who have not experienced it, but the fact that there was no help other than what I could provide for myself, caused me (or perhaps the better word is “forced” me) to expand my interior horizons in ways I could not have anticipated.

    I don’t mean to romanticize my experience, and I am not recommending that anyone follow the path that I chose. I certainly don’t think anyone should have the right to inflict suffering on anyone else, and I’m also aware that I have been very fortunate in experiencing four births at home without any complications. However, my response to this discussion is to share my experience: I was amazed to discover that as an unexpected bonus (along with the baby), I learned things about myself that were true gifts. Giving birth had ended up being emotionally and spiritually very meaningful to me.

    Meanwhile, my sister-in-law, who had a baby at about the same time, loved her hospital birth with an epidural. She said she played cards, sipped champagne, and told jokes until it was time to push. They then let the epidural wear off a bit, she pushed out her baby, and that experience was very meaningful to her.

    So, “Are epidurals the answer?”

    It depends who’s asking.

  78. Chris says:

    DJ Lane:

    She said she played cards, sipped champagne, and told jokes until it was time to push.

    Cripes! All I was allowed were ice chips!

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