THE RISKS VS BENEFITS OF EPIDURAL ANESTHESIA

By: Elena Lyons   /   Jul 09, 2012   /   Blog, Maternity   /   Comments

This article was written by Tonya Brooks and I admire her courage for reporting the side that isn’t being told.

FOR LABOR: SHORT TERM BENEFITS AND LONG TERM QUESTION
Most women who have experienced the pain relief of epidural anesthesia swear by them. One email stated, “My experience with an epidural was very positive. It did slow down labor however, requiring the use of Pitocin. Once the Pitocin was administered labor went quite quickly. The epidural did not inhibit the baby’s progress down the birth canal. When it came time for me to push, I was numb but I could do it. To my knowledge neither I nor the baby suffered any adverse effects.”
However, long-term outcomes are not measured by Apgar scores or how alert babies are at birth. There are fourteen studies in child development journals, pediatric and maternal/child nursing, and obstetric journals which link specifically epidural drugs to long-term learning disabilities such as hyperactivity. Mounting evidence suggests epidural anesthesia – including the drugs, doses and combinations – should be studied from a point of view of long-term outcomes. Many physicians are reluctant to discuss the ramifications of epidurals because they feel women must have access to pain relief in labor. For mothers who need them, for reasons related to cesarean sections, epidurals are far safer than general anesthesia and spinals (epidurals given deeper). But studies we do have compare the effectiveness of one drug against another rather than compare medicated birth against those births that are drug free.
When a mother’s blood pressure is lowered by the epidural, a fetus with poor placenta reserves receives lower oxygen levels causing a reflex that shunts blood from the gut to the vital organs: the brain, heart and adrenals. Occasionally that safety mechanism is severe enough to deprive the intestines of enough oxygen to damage them. The long-term consequences are complex but this can cause digestive disorders in the infant. The problem with a baby that does not digest well is that the infant is developing the top lobe of the brain until he is nine months old. It is critical for the brain development that infants properly digest food. Brain injury is often minimal but cumulative. So before one settles for the pain relief of an epidural anesthesia, it is worth understanding and investigating benefits versus the risks.
Statistics show the use of epidural anesthesia for pain relief in labor is on the rise. It has reached up to 90% in some hospitals, depending on the city in the U.S. It is touted as safe and in fact mothers are told that drugs given in this fashion as an epidural does not reach the baby at all. This has been translated by the public at large to mean that epidurals are without risk to the mother and the baby and there is no need to labor the natural way. Nothing could be further from the truth.
The use of epidural in labor does the following:
(1) It interferes with contractions and thus the progress of labor.
(2) By decreasing the strength of contractions, epidural anesthesia may require the use of Pitocin – a synthetic version of one’s own hormone, which causes the uterus to make stronger contractions than it normally would. The stronger contractions do two things: first, they squeeze the blood vessels feeding oxygen blood to the placenta that is already compromised by the decrease in maternal internal blood pressure and, second, Pitocin can make a uterine contraction strong enough to push the baby into the pelvis in a poor position. This raises the cesarean rate for failure to descend through the pelvis.
(3) Pitocin has also been implicated as a contributing factor in increased neonatal jaundice.
(4) Pitocin in conjunction with anesthesia must be monitored internally so that the dose given does not cause contractions strong enough to rupture the uterus. Also internal monitoring increases the risk for maternal and infant infections. Internal monitoring decreases the mobility of the mother in labor and she must remain in bed.
(5) Because epidural anesthesia lowers maternal blood pressure, it cannot be used without IV fluids that assist in keeping maternal blood pressure up to safe levels. Lower blood pressure in the mother can cause a condition called “utero-placental insufficiency”. Utero-placental insufficiency can cause fetal distress and cesareans for rescue.
(6) The kind of drugs used in the epidural is usually a local anesthetic and a narcotic combo. Women are told that because these drugs are a local anesthetic they “do not reach the baby”. We have known since 1972 from Harvard studies that the “caine” drugs cross the placenta in 18 seconds in 40-60% of the maternal load. In other words, fast acting drugs will be in a higher concentration in the maternal blood stream quicker. The narcotics with which they are mixed cross the placenta with ever beat of the mother’s heart. These drugs are categorized as central nervous system depressants and may cause a decrease of the baby to breathe at birth. If this occurs, the baby must be given a drug called Narcan to block the effect of maternal anesthesia and breathing is established by resuscitation.
(7) Because the epidural interferes with uterine contractions, it can interfere with fetal rotation and descent (the ability of the baby to rotate in and come through the maternal pelvis). This increases the likelihood of “failure to progress” by decreasing descent, dilation or both and markedly increases the chance of a cesarean section. A cesarean section puts the mother’s future births (even pregnancies) at risk for uterine rupture, but that will be dealt with elsewhere.
(8) Because epidural anesthesia causes relaxation of deep muscle, little to no feeling and decreased sensation of pressure, it is difficult for many – not most – mothers to push; and prolonged pushing increases the risk for operative deliveries such as out forceps or vacuum extractions. This lack of ability to push can be corrected if the epidural is turned off. But the effect of the anesthetic on the baby is still there. The second stage of labor (pushing) is important to the infant’s well-being and long-term outcomes. Uterine contractions peak faster and maintain their peak longer causing decreased blood flow to the placenta, while maternal cardiovascular output decreased in the second stage of labor. Moreover the maternal anesthetic decreases the fetal neurological response to oxygen deprivation. In the “at risk” fetus such as premature or growth retarded babies or babies with infection, this can cause significantly low oxygen levels.
(9) In addition, the drugs used in epidurals carry the risk as a neurotoxin; however, this is rarely studied because many physicians believe pain relief to be necessary to any woman in labor. If one assumes all women need pain relief then the increased risk of cesarean sections, fetal distress, post-partum hemorrhage, and maternal deaths are acceptable risks. In fact, the safety studies for the last several years DO NOT state if the drugs reach the baby or their effects instead they study one form of anesthesia against another for effectiveness. Again, they DO NOT focus on what the drugs actually do to the mother or baby. One of the few exceptions is the study done by Yvonnne Brackbill, MD and Sam Broman.
In summary, epidurals are not without long-term risk to mother and baby. Lowering maternal blood pressure in a fetus whose placental reserves are poor is likely to produce oxygen starvation depending on the underlying condition of the baby and it is related to future behavioral problems. This is certainly enough to produce long-term problems for the child.
No researcher is saying “never have anesthesia” but the long-term effects are not being adequately studied and the physical consequences are quite real, so the best approach depends on the physical circumstances.
And still the best way to protect one’s baby in a normal vaginal delivery is to have an unmedicated birth or “natural childbirth”. Good childbirth classes should give mothers and coaches a wealth of information to cope with labor without drugs. One of the biggest purposes for midwives is to help mothers create births where pain is minimized by laboring in water and with the loving support of family and friends. This article has not focused on the incredibly empowering experience that childbirth without drugs can bestow but the emotion of birth is profound and lifelong. I hope all women will get trained and rethink their plans. With natural childbirth, most women will experience the joy of conquering pain, and child development specialists will see fewer cases of hyperactivity and all that goes with it.