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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  • There is no justification for outdated practices of delaying epidurals until cervical dilation is advanced or for stopping the epidural during the last stages of labor.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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