“The only thing as consistent as birth pain has been the search to eradicate it, pharmaceutically” – Tina Cassidy, Birth: The Surprising History of How We Are Born
Pain medications in childbirth have been sought for millennia. Egyptians used opium, the Greeks chewed willow bark and, on a mythical level, Artemis asked Zeus if she could remain an eternal virgin just so that there would be no chance of experiencing the pain of childbirth! Later in history (around the 1850‘s) ether and chloroform became popular medications in childbirth, until it was proven that these anesthetics were transferred to the newborn during labour and delivery. From 1914 to the late 1960‘s, the new fad in pain relief in childbirth was ‘twilight sleep’, or scopolamine & morphine, whereby a woman was rendered completely immobile and/or semi-conscious in labour and childbirth. This method became unfavourable in the 1960’s and 70’s when women began to question their lack of agency in labour and childbirth. There were also dangerous side-effects to scopolamine (mainly hemorrhaging and transference of medication to the newborn), hence it became an unpopular method of pain relief and its phasing out made way for the most common and effective pain relief in labour and childbirth that is still used today – the epidural. (Cassidy, 2006)
The epidural, along with all manner of pain medications or analgesics, is among the most frequently prescribed and used medications in the developed world. The reason is that medical professionals are trained to reduce – or even try to eliminate – pain in their patients. This is an absolute necessity in treatments such as surgeries and invasive procedures, whereby the pain is not a normal and expected consequence.
In labour and birth, the treatment for pain gets complicated, and sometimes controversial. Childbirth is not a medical condition that requires pain relief but the opportunity to avail of analgesics in labour and birth has, as discussed above, been sought throughout history and it has particularly become a much lauded choice over the last 50 years, since the advent and popular use of the epidural. Pain relief should be available to all women in labour and birth, should they want it; however, with all birth choices the information should be accurate and up-to-date and there should be scientific evidence to support any and all interventions. Following on from our theme from last week, when making an informed choice – in any medical environment – the evidence should be presented in a non-judgmental way and individuals should be able to make their informed choice or informed refusal based on that evidence.
In labour and childbirth, 70% of first time mothers choose epidural analgesia in Irish hospitals. This percentage drops significantly for second time mothers in Ireland. Some practitioners argue that it is inhumane to allow a woman to give birth without the option of pain relief. Others believe that a woman’s body is equipped to cope with the pain and that it serves a physiological function in labour, birth and postpartum.
The controversy over the use of epidural for pain relief in childbirth is often related to the cascade of interventions that accompany this method of pain relief. For example, the Cochrane Review (Anim-Somuah, Smyth and Howell, 2010) on epidural versus non epidural, or no analgesia in labour, outlined three common downsides of epidural:
- an increase in forceps or vacuum delivery
- a lengthening of labour and
- an increased need for oxytocic drugs (as discussed in the article Epidural – Is It Right For You?)
But in the last decade, the research on the side effects of epidural pain relief have begun to look beyond the simple hypothesis of whether epidural is effective in reducing pain (Answer: IT IS!) and studies have begun to look at the relationship between the use of epidural and longer-term neonatal outcomes.
We know from the Cochrane Review that “epidural analgesia has no immediate effect on neonatal status as determined by Apgar scores” (Anim-Somuah, Smyth and Howell, 2010, p. 2), but this same review stated that while the use of epidural analgesia did not present any statistically significant immediate effects on a newborn baby, longer term consequences are not yet known. The Apgar is taken twice – at one minute and again at five minutes immediately after a baby is born. The Cochrane review could not make any conclusions on the first few hours or days of a neonate’s life and the possible side effects of epidural analgesia as none of the research studies being reviewed included any longer term data on neonates.
An increasing area of study with neonates in relation to longer term effects of epidural is looking at the establishment of breastfeeding. It is well known among breastfeeding information and support advocates that the first few hours and days postpartum are crucial in establishing and maintaining the breastfeeding relationship. If a baby is sleepy or has difficulty latching, this can present a barrier to a new mother who is not familiar with breastfeeding and/or who may feel that the baby is not hungry or does not want her milk. All intrapartum (ie. the time of labour and delivery) factors that may be related to a mother’s difficulty with establishing a breastfeeding relationship, if this is what she is choosing, should be investigated in order to help restore a mother’s confidence in her ability to establish and continue breastfeeding. This is what has led investigators to look at one of the most common treatments in labour and birth – the epidural – and to uncover any links that may be associated with breastfeeding rates.
However, the covariate factors are difficult to separate when looking at epidural anesthesia and breastfeeding because, as the Cochrane Review concluded, there are other proxy reasons that may also contribute to neonatal health and the breastfeeding relationship. If an epidural is used during labour and birth – in addition to oxytocin, pethidine and an instrumental delivery – then how can research conclude that it was the epidural anesthesia that caused a neonate to be drowsy and slow to latch on to the breast? This is what has made researching the effects of longer term neonatal outcomes such a difficult task – the heterogeneity of the research subjects (ie. the differences between them) and their varied pathways of care. Each mother who has an epidural also has her own birth story with several contributing factors – both in her care and in her life – that converge to either support or hinder the establishment of breastfeeding. For women who choose to formula feed this may not be of any consequence but for those women who are looking forward to breastfeeding and who have chosen this method of nourishment for their babies, the possible connection between epidural anesthesia and any other avoidable barriers to breastfeeding are important to identify and resolve.
One recently published study by Dozier et al. (2013) was able to address several of the methodological limitations for which some of the other research papers in the past have been criticised. Too many studies have not looked closely at ALL the contributing, or covariate, factors when studying the relationship between epidural analgesia and breastfeeding. One of the most compelling conclusions that the well-designed Dozier et al. study found was that “mothers receiving both epidural anesthesia and IV oxytocin represent the group most likely to cease breastfeeding within 1 month postpartum, while mothers receiving neither represent the lowest risk group” (Dozier et al., 2013, p. 694-695). This research may have opened up a further avenue of study in relation to the use of epidural and the resulting increased risk of IV oxytocic medication and how this can have a detrimental affect on the breastfeeding relationship.
Perhaps the most salient conclusion of the Dozier et al. study is that the combination of the use of epidural in conjunction with other medications – most notably IV oxytocic agents – is very effective in relieving pain and augmenting labour but it also suppresses the body’s production of endogenous oxytocin, which is essential to milk ejection and milk production (Jonas et al., 2009).
So what conclusions can be made about the use of epidural pain relief and breastfeeding? So far, it seems we are only at the beginning of the journey of understanding the intricate co-action of pain, oxytocic hormones and analgesics and how they all combine to either help or hinder labour, birth and breastfeeding. In the end, it is a woman’s choice to avail of epidural and other analgesics – particularly if she feels it is going to ease anxieties associated with the pain of labour and childbirth. At the same time, a woman who is going to give birth deserves to know that a choice of epidural is frequently accompanied by other medications and interventions that can affect her birth and breastfeeding experiences. Armed with this knowledge – you are free to make up your own mind and to choose what will work best for you in your labour and birth.
Anim-Somuah, M., Smyth, R.M.D., and Howell, C.J. (2010) Epidural versus non-epidural or no analgesia in labour (Review). Cochrane Library, Issue 8. John Wiley and Sons, Ltd.
Cassidy, T. (2007). Birth: The Surprising History of How We Are Born. New York: Grove Press.
Dozier, A.M., Howard, C.R., Brownell, E.A., Wissler, R.N., Glantz, C., Ternullo, S.R., Thevenet-Morrison, K.N., Childs, C.K. and Lawrence, R.A. (2013). Labour epidural anesthesia, obstetric factors and breastfeeding cessation. Maternal and Child Health, 17(4), pp 689-698.
Jonas, K., Johansson, L.M., Nissen, E., Eideback, M., Ransjo-Arvidson, A.B., and Uvnas-Moberg, K. (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. Breastfeeding Medicine, 4(2), pp 71-82.