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March 28, 2005
News this month Although about 60 percent of American women in labor currently receive epidurals, there has been considerable controversy about when it is safe to administer the pain-relieving medication, particularly for first-time mothers. “There has been considerable controversy about when it is safe to administer pain-relieving epidurals.”
Studies conducted in the 1990s indicated that epidurals given before a woman's cervix was dilated at least four centimeters—nearly halfway to the 10 centimeters needed for a normal delivery—could lead to longer labors and a higher risk of Caesarean sections. Many doctors believed that epidurals early in labor could interfere with uterine contractions and a woman's ability to push. These physicians administered systemic narcotics for those requesting pain relief. Other researchers suggested that the prolonged labors and higher Caesarean rates associated with those women requesting early epidurals might be a result not of the epidurals but of very large babies or babies turned in the wrong direction. Study shows no negative effects of early epidurals A study published in the New England Journal of Medicine challenges the practice of withholding epidurals until advanced labor. In this study, conducted at Northwestern Memorial Hospital in Chicago, women given epidurals before the dilation threshold of four centimeters actually had faster deliveries, better pain relief and no increased rate of C-sections, compared to women who received narcotics for pain relief. In the study, physicians used a low-dose pain relief known as “combined spinal epidural.” A small dose of medication is injected in the spinal fluid and the epidural is later fed through the same hole into a space farther from the spine. The C-section rate was statistically a tie between the early epidural group and the narcotic injection group.
In this study, 750 women in early-stage, first-time labor were divided into two groups. One group received a spinal anesthetic and the other group received narcotic injections at the first request for pain relief. At the second request, the women who had received spinals were given epidural anesthesia; the injection group received a second narcotics injection. After that time, women who received narcotics were given epidurals when they reached four centimeters or when they asked for more pain relief. In the end, the C-section rate was statistically a tie between the early epidural group and the narcotic injection group: 17.8 percent vs. 20.7 percent, respectively. The women with spinals experienced an hour and a half less of labor than the narcotics group, and they reported much less pain—two vs. six on a 0-10 scale—than the injection group. Dr. Cynthia Wong, lead author of the study, said women are often
pressured to delay epidurals and made to feel guilty or weak if
they asked for one too soon in labor. “Women say: 'I
must be a wimp. I had to ask for pain medication so early,'” Dr.
Wong said. “The bottom-line message is that if you're
a first-time mom in early labor and it hurts and you need pain
medicine, by getting this kind of spinal-epidural you're
not at increased risk for a C-section, and there are benefits to
doing it this way.”
Physician Referral
Online A free and confidential service of Yale-New Haven Hospital. Physician Referral Online Using your own criteria, you can request information from a database of more than 1,000 area physicians who have registered to participate. Request an appointment We would be happy to assist you in scheduling an appointment with a member of the hospital's medical staff. Use the link above or call: 203-688-2000 or toll-free 1-888-700-6543 to talk with a referral coordinator. 
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 Epidural study may relieve anxiety about pain relief This very well-designed study provides the data that demonstrates what anesthesiologists have long observed among their patients: Epidural pain relief does not negatively affect the outcome of a birth experience for the mother or baby. Our goal is for our patients to safely and healthfully deliver their babies the way they choose to-with or without pain medication or epidural analgesia.
“Epidural pain relief does not negatively affect the outcome of a birth experience for the mother or baby.”
Not your mother's epidural Women can push, and, if they choose, they can get up and walk around. Our experience indicates most women are exhausted in labor and would rather rest than walk, but they do have that option. Women may still feel contractions; patients often report feeling like they're having menstrual cramps. For those women who don't want to feel those sensations, we can adjust the medication appropriately. Epidurals deliver pain-relieving medicine through a skinny plastic tube that is threaded into the back, close to spinal nerves, bypassing the mother's bloodstream. We've welcomed epidurals as an alternative to “systemic” pain medicine that passes through the bloodstream, which can leave some women feeling nauseated and drowsy. The placement of an epidural does cause some discomfort, but patients say the discomfort is well worth the option of having a less painful labor and birth experience. We have noticed that women who receive spinal narcotics (analgesia) very early in labor—and that is actually a small percentage of women—may become fully dilated more quickly. One theory is that pain increases the secretion of fight or flight hormones such as adrenaline, which may slow the laboring process. Once pain is relieved, the hormone secretions stop and contractions continue. Not safe for everyone Who shouldn't have epidurals? Women who have systemic infections, bleeding disorders or who are taking anticoagulants should not be given an epidural because of an increased risk of an abscess or hematoma. And certainly, any woman who does not want an epidural for any reason should not be given one. What I try to communicate to patients is that it's a good idea to come to the birth experience with few expectations regarding pain medications. We don't want anyone to feel as though they've somehow failed because they've received pain relief. We encourage women to learn as much as possible about pain relief options before labor since knowing your options and any associated risks of those options can help you make the best choice for you. The good news about this study is that a woman who wants pain
relief can choose an epidural without worrying about negatively
affecting her labor, her health or her baby's health. Dr. Braveman is an attending obstetrical anesthesiologist at Yale-New Haven Hospital and a professor of anesthesiology and section chief of obstetrical anesthesiology at the Yale University School of Medicine.
For the 13th year in a row, Yale-New Haven has been highly ranked by U.S. News & World Report for its programs in gynecology. |
