The Epidural Trip
Why are so many women taking dangerous drugs during labor?
by Judy Slome Cohain

[Editor’s note: This article first appeared in Midwifery Today Issue 95, Autumn 2010.]
Photo by Patti Ramos Photography

Abstract: Two million American women will take an epidural trip this year during childbirth. In most cases, they’ll be ill-informed as to possible side effects or alternate methods of pain relief. In many ways, epidurals are the drug trip of the current generation. Similar to street drug pushers, most anesthesiologists in the delivery rooms maintain a low profile, avoid making eye contact and threaten to walk out if they don’t get total cooperation. Women get epidurals for one of the main reasons so many women smoked pot in the 1970s—their friends are doing it. This article examines why so many women in the Western world are compelled to take powerful drugs during their labor and exposes the risks epidurals pose to both mother and baby.

Photo by Patti Ramos

[Photo by Patti Ramos pattiramos.com]

This year, about two million women will get an epidural legally, but hopefully not lethally, in the US. As a result, about eight of them will never walk unassisted again. In Westernized countries, roughly 50–70% of birthing women have epidurals for pain relief. Research on who gets an epidural and why draws a profile very similar to the people who were taking drugs in the ’70s. Most women are getting epidurals because their friends are doing it.(1) In a recent, large study of epidural users, the most often cited factor in deciding to have an epidural was having heard about positive experiences from friends and family. Having already had children and having fear of the side effects of an epidural each reduced the odds of choosing one by half. In other words, the older or wiser women get, the more they avoid the epidural trip. Overall, those who did not choose an epidural reported wanting to be in control and having more confidence in their ability to tolerate labor pain.(2)

The typical epidural is a combination of two powerful opiates: fentanyl and bupivacaine. Fentanyl has 80 times the potency (and side effects) of morphine. Bupivacaine has the ability to cause tingling around the mouth, tinnitus, tremors, dizziness, blurred vision, seizures, depression, loss of consciousness, respiratory depression and/or apnea. Bupivacaine has caused several deaths by cardiac arrest when an anesthesiologist accidently inserted the epidural analgesia into a vein instead of the epidural space in the spine.

Today, health authorities tout epidural analgesia as the safest, most effective method of pain relief available for childbirth. You could not pull that off on my generation. We lost enough creative artists—Janis Joplin, John Belushi, Jim Morrison and Lenny Bruce—to injectable pain killers. We are aware of the potential of painkillers that are injected into your body—let alone into the delicate spinal cord—by someone else. We know that epidurals do not compare in safety to asserting the power of mind over body, hypnosis or even group high. Those three involve no danger and are all as effective as epidural anesthesia. Pain, more than any other sense, is open to individual interpretation. This is particularly true when it comes to the pain of childbirth.

Watching a woman get an epidural reminds me of watching a teenager have a bad drug trip. Birth is not a terribly painful process in the comfort of home, although going to the hospital doubles it. At home, the part that hurts enough so that you can’t sleep through it typically lasts 2–12 hours, and even then, the pain is neither continuous nor pointless. Labor is a series of 30 seconds of pain followed by 2-, 3- or 4-minute intervals without pain. During that interval between pains, a woman can sleep, talk to friends, work, paint, cook, sing, read, do absolutely anything her imagination can dream up. She is in no pain. The task of labor is to breathe and relax for 30 seconds of contraction. This can easily be accomplished by the most unimaginative person by walking slowly and counting 10 slow breathes. An imaginative person can connect to the place in her body where she can release her natural endorphins and get a natural high. She can surround herself with a few people who love her and get a contact group love surge. She can connect to her power or whatever power she wants to let flow through her—it’s much like the energy you get watching a great concert, or a shooting star, or a child take his first step. As this energy flows through her she can imagine herself powerful and giving life force to others, praying for the health of sick people she may know. She can kneel down in soft, green grass and suck in nature’s bounties. It can be tiring, but the longest it will last at significant strength is 12 hours. If labor lasts longer than this, the contractions usually slow down and the woman can sleep a bit. If one needs pain relief to help release endorphins or sleep, three acetaminophen will work. Most women who hear that Tylenol works in labor ask me why they don’t give it in the hospital. I tell them that I have absolutely no idea.

Walking through labor on her own path helps establish the type of self-confidence that is needed for mothering. You are upright and in your own home. No one is shaping your birth for you. You create your own reality. You find strength for the challenges of nursing and motherhood.

The biggest lesson I’ve learned from 25 years of assisting births is that there are no two people on earth alike. Each woman is a completely unique entity with different tastes, needs and desires. By enabling a woman to birth at home—or in any place she chooses—where she can find the position, place, smells, atmosphere and surroundings she needs to birth, she can birth practically without pain. I am not only referring to people who meditate and do hours of yoga every day. I’m talking about Mrs. Couch Potato, too. I could describe hundreds of women who did not feel much pain during birth.

Yesterday, I had just such a birth. When I arrived, she was in early labor, 12 hours after her water broke. We all agreed that perhaps she was stopping herself from going into strong labor for all kinds of psychological reasons. It was her third child. We all went to sleep for a couple of hours. When her husband woke me up two hours later, the mother seemed fully dilated, sitting on the toilet spraying herself with the water from the shower handle. The bathroom was covered with water and an inch or two of water covered the floor. Although it was her third vaginal birth, she said she did not believe in her ability to push. She did not want to get in the bathtub, where I suggested she could be surrounded by water and have something to lean her back against. She did not want to go to her bedroom either. She decided to sit on the floor of her tiny bathroom leaning her head on the toilet seat, sitting in an inch of cold water. It didn’t seem comfortable to me, but it was for her. In fact, she said that in this position, the labor was painless. She said it then and she repeated it after the birth. She sat there for an hour, not pushing during contractions. During the hour, the fetal heart rate was reassuring and I told her so. I occasionally whispered to her how great she was doing. Finally, she gave a very large, strong push and pushed the baby out. She said, afterwards, that for the first hour, she just didn’t realize, “It was up to me!” She said it was a lesson that applied to her life in general, not just birthing. This could have never been learned in a place where she could not direct and choose the path of her birth, i.e., sitting in an inch of cold water on the floor in no pain, learning the lessons of life. This kind of emotional growth does not take place under the influence of epidural anesthesia. You have to be in a position to make personal choices for yourself.

How to Take an Epidural Trip

If women could take an epidural themselves, the FDA would make it illegal for women to do so, probably using the excuse that it is deadly and lacks adequate research. Although the euphemism, “She took an epidural” is universally used, no woman can take an epidural. She has to be given it. She doesn’t get to administer the drug herself or choose the dose or the timing. The only active part of epidurals is agreeing to one and signing the triplicate, multi-colored consent forms.

The procedure is as follows:

First the current drug birth culture doubles the laboring woman’s pain by putting her in a $10,000 hospital bed with two sensors (each three inches in diameter and about the weight of a coffee cup) strapped tightly around her belly with wide, elastic belts. The continuous fetal monitor makes her constantly aware of being in a hospital and focuses her attention on the pain. She can’t turn, walk, or lie in a bath. There are two hospitals in Canada, though none in the US, that routinely use epidurals that permit walking and avoid some of the other “side effects” of epidurals, but most physicians and midwives have never seen it. 

Then the woman has to have a two-inch long plastic cannula placed into a vein in her arm to really convince her that she’s being treated for a severe car accident or a ruptured appendix rather than the birth of her child. Then the authorities ask her in a sweet, kindly voice whether she is interested in an epidural. It will have no effect on the baby, they tell her. Any other pain relief will affect the baby, they tell her. It is true that for the purpose of anesthesia during cesarean, epidural anesthesia causes less respiratory depression of the baby than general anesthesia. But extrapolating from the relative safety of its use for cesareans to stating that epidural is the safest anesthesia for vaginal birth has no basis. Not until long after she has verbally agreed to the epidural and the IV is loaded and the woman is beached in bed with her monitor, only then will a distant, impossible-to-track-down anesthesiologist appear. Like street drug pushers, the anesthesiologist often seems to makes him or herself scarce. (For stories about this visit www.MyOBsaidwhat.com.) The comparison does not stop there. Often the midwife, nurse or doctor will make it clear that there might be no anesthesiologist available for hours. The streets are dried up. When the anesthesiologist arrives, the woman is usually relieved by her luck that this hard-to-find anesthesiologist happened to have a minute to supply her. The doctor enters, picks up the chart, and with barely a glance at the woman, asks the same 10 questions that the woman has repeatedly answered since her arrival: allergies, general health, no previous surgeries, etc. In the same monotonous tone, without ever making eye contact, the anesthesiologist pushes the consent form and pen into the woman’s lap, rattling off all the possible bad effects of epidural while the woman is sitting up on the bed, already in position to have the epidural, and often while having a contraction and unable to pay attention to what is being told to her. The anesthesiologist is reluctant to answer questions. In response to questions, there is usually a “I have better things to do” tone of discourse. The nurse is already gloved and masked, waiting to hand sterile objects to the anesthesiologist.

What a surprise that the woman in labor, who’s been waiting for her fix, says, “Why yes. Give me what you’ve got.”

Now the fun really starts.

The anesthesiologist takes a large gauge needle on a 5 or 10 cc syringe and starts digging into the laboring woman’s back. The hole has to be large enough to fit the drug-bringing cannula which goes in 4 inches, or 10 cm, in and up her spine. Blood flows down her back in a half-centimeter stream from the hole. It hurts to be stuck. The hole will hurt for a few days like any wound. During this time, the woman in labor has to stay absolutely still during her contractions. The anesthesiologist explains to her that if she moves, the needle may tear the epidural membrane in her spine. The anesthesiologist threatens her that she can cause a terrible headache if she makes a slip or, alternatively, cause a hematoma which may result in permanent spinal damage. Amazingly, this woman who was writhing and moaning with pain just a few minutes before is now absolutely silent and doesn’t move a hair during the contractions that were so very painful just a minute before the anesthesiologist arrived.

Is she aware of her ability to have strong contractions at 5 cm dilation, seated under fluorescent lights while a total stranger carves a hole in her spine, merely by breathing in a careful, concentrated manner? No one points this out to her. The epidural is her choice, the midwife whispers to me. I certainly would get thrown out of the hospital by the cultural majority if I went around pointing this out to women. But I must write it for those who desire to know. Anyone who has the mental and physical strength to sit through strong, painful contractions without budging a single muscle, in the bent-over, uncomfortable sitting position required for getting an epidural, for 10 long minutes, on a raised bed, under bright fluorescent lights, while a strange, unknown anesthesiologist sticks a large needle in her back, can have an easy attended labor in the comfort of her own home, without any need for pain relief beyond a few Tylenol capsules. This is a fact that needs to be told to her.

Once the epidural is in, she is expecting full pain relief for her efforts. At least 5% of women get no relief whatsoever from the epidural. The epidural does nothing, except leave a painful wound in her back. The risk factors for receiving no pain relief from an epidural include (3):

  • obesity
  • multiparity
  • history of a previous failure of epidural anesthesia
  • cervical dilation of more than 7 cm at insertion
  • the use of air to find the epidural space while inserting the epidural instead of other things like N2O saline or lidocaine
  • being a regular opiate user

Due to the intervention of the normal labor process, this woman—1 out of every 20 women who get an epidural feels no pain relief—must now go through the pain of labor on her back with a fetal heart monitor attached to her belly and an IV running into her veins through her arm. She will not be allowed to get up to urinate or defecate in the toilet, but will have to use a bedpan. She may be catheterized for urine and given suppositories to defecate. She is a beached whale and will not have any pain relief whatsoever. The staff will tell her that she is mistaken. They will tell her the epidural is working.

For the other 95% of women, the epidural will either work partially or fully for 30 minutes to an hour. I do notice that many young women today are excited about what is often their first drug experience. They get a little buzz and feel a bit tingly high from the relief of pain and the fentanyl and smile from the high. It seems a shame that they are unaware that they could get that high by learning how to find the place inside themselves that releases it naturally, or by surrounding themselves with other high people. Also, if the woman feels the fentanyl high, then the baby must be getting it also, which probably accounts for the many babies who have difficulties nursing after an epidural birth.(4) Obviously, sometimes the fentanyl comes out of the spinal column and enters the bloodstream. This also explains why many women get the “fentanyl itch,” a full-blown red, itchy rash that spreads across the woman’s chest.

Although high doses of epidurals can bring complete anesthesia for use during surgery, including cesarean surgeries, anesthesiologists resist using high doses during labor because of the possible side effects.(5) The anesthesiologist gives a large loading dose, but then the woman receives a low continuous dose after that. Usually this means that the epidural only works for 30 minutes to an hour and then the main effect wears off. After that, the woman starts feeling the pressure of her contractions and, frequently, the pain of contractions. However, again, she is unable to get up and walk around and use her imagination and power, because she is forced to stay in bed, attached to the monitor, having to urinate in bedpans or be catheterized until after she delivers.

The epidural slows down labor significantly—meaning a longer labor overall, which equals more pain, not less. The following are accepted explanations for why this happens:

  • The release of oxytocin is decreased with epidurals.(6)
  • Lack of gravity: the woman is lying down instead of standing up.
  • Lower blood pressure, which also slows oxytocin release.
  • Malpositioning of the baby’s head to transverse or posterior.

Epidurals cause a relaxation of the pelvic muscles, which were previously working to help the baby descend in the correct position. With the relaxation of the pelvic muscles, the baby frequently turns into a posterior position or some other non-optimal position, with the heaviest part of his head falling to the back of the pelvis, leaning on the spine with his face facing up. This causes the contractions to be less effective. Posterior position increases the length of labor. It is a harder, longer, more painful labor because the back of the head, instead of the face, is pressing against the spine.

Most women with epidurals feel the sensations of the second, or pushing, stage of labor. They feel the baby’s head pressing on their rectum. They usually experience this as pain. Although the first stage may have been painless, now they feel the labor after full dilation because the epidural is wearing off. Once the woman is fully dilated, the woman often feels everything as if she had not had an epidural, or worse because her expectation was full pain relief. Now she is feeling all the pain of pushing and it’s worse because she didn’t expect it. She is disappointed in what she may think of as her body’s failure to be anesthetized.

Finally the baby comes out. It always does. No matter what you do to women, the baby comes out one way or another. You can’t put the baby on her belly, because first you have to open the belts holding the two large monitor sensors and then take the monitor sensors off her belly. Then you can pass her baby to her. Finally the baby is on her mom’s belly. The monitor is off, the mother is relieved. Administration of epidural analgesia has been found to delay onset of breastfeeding and to shorten breastfeeding duration in women.(6) In this first study looking at breastfeeding two days after epidural anesthesia, it was discovered that epidural analgesia in combination with oxytocin infusion causes the woman to have significantly lower oxytocin and prolactin levels in response to the baby breastfeeding, even two days after the birth, which means less milk is being produced. This is a critical side effect, because most women with epidurals do end up with a Pitocin augmentation because the epidural decreases the release of natural oxytocin.

At an empowered woman’s birth, the baby’s land life starts with a reassuring breastfeed, easing his transition into extra-uterine life with associations of unrestricted love, warmth and happiness, laying the groundwork for a life in which he searches for more experiences of the same kind and questions authorities that offer other types of experiences.

References:

  1. Van den Bussche, E., et al. 2007. Why women prefer epidural analgesia during childbirth: the role of beliefs about epidural analgesia and pain catastrophizing. Eur J Pain 11 (3): 275–82.
  2. Ibid.
  3. Agaram, R., et al. 2009. Inadequate pain relief with labor epidurals: a multivariate analysis of associated factors. Int J Obstet Anesth 18 (1): 10–14.
  4. Mothering magazine Web site. http://www.mothering.com/articles/pregnancy_birth/birth_preparation/hidden-risks-epidurals.html. Accessed 23 Mar 2009.
  5. See Reference 3.
  6. Jonas, K., et al. 2009. Effects of intrapartum oxytocin administration and epidural analgesia on the concentration of plasma oxytocin and prolactin, in response to suckling during the second day postpartum. Breastfeed Med 4 (2): 71–82.

Judy Slome Cohain, CNM since 1982, MS, is devoted to illuminating the field of women’s health with objective evidence, based on the scientific method.


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