Do epidurals increase the odds of needing a Cesarean birth?

Anyone who loves and appreciates a woman in their life – mother, daughter, sister, friend – ought to care about women’s rights, am I right?

And the rights of childbearing women specifically include the right to know about the risks associated with anything that could potentially enter a woman’s body during childbirth. It should go without saying, but we do have a right to fully understand what is being put into our bodies if we so choose.

And some women will choose not to know. But all too often the risk is brushed aside and deemphasized. Women hear statements along the lines of: “No need to be a martyr, sweetie.” “Why would you do that [natural childbirth] to yourself?”

Think about it: we’re trying to get something to come out, to be born, during childbirth, yes? In my opinion, we need to closely examine what’s going in to find out how that could impact the process – positively or negatively.

Why does it matter? Why can’t every woman expect to have complete pain relief during childbirth while also bonding and feeding her infant immediately after birth with absolutely zero health complications?

Well, let’s examine one of the most common substances to enter the body during childbirth: epidural anesthesia. If you’re looking for even more specific research on the topic (which my post will not cover), check out Science & Sensibility’s newest post.

The epidural is a cocktail of drugs, including narcotics. Strength-wise, it’s somewhere in the middle of what we receive at the dentist’s office and cocaine; it will depend on the anesthesiologist somewhat as to the dosage he/she decides to give. “Fourteen” would be about the highest that would be given. At “12,” a petite person may be able to get a little bit of the pressure sensation of the contractions back in order to participate in the pushing process, so after an epidural is given and a woman’s cervix is completely dilated, the provider may suggest turning down the epidural for that purpose. Great idea, but the only problem with it is that usually when women become accustomed to the sensation of complete numbness, they are less willing to accept getting any of that sensation back.

Something that surprisingly tends to get ignored in the discussion about epidurals is that it’s helpful for a woman to participate in childbirth. Imagine that!

There is such a thing as a “walking” epidural, where the dosage of regional anesthetic is lower (allowing for less numbness and more sensation in the lower body), while the dosage of narcotics is higher, allowing for more pain relief. Theoretically this could allow a woman to participate more fully in the birth of her baby while also experiencing adequate pain relief. Can she walk? Nope.

However, narcotics do cross the placenta and can therefore affect the baby (the least of which could be less alertness and less desire to nurse at birth, and in more severe cases, respiratory depression). So although the idea of a walking epidural is smart, the added risk does concern me. I believe this is likely the reason why most hospitals prefer more regional anesthesia and fewer narcotics in the epidural cocktail.

So typically we’re left with complete or near-complete numbness in the lower body in order to attempt to protect the baby from potential complications. Quite commonly there is higher risk of jaundice in the newborn after a medicated birth; what sometimes happens is the mother is discharged from the hospital before her infant, which may create additional separation between mother and infant – basically the last thing a jaundiced baby needs.

epidurals can increase risk of Cesarean birthNumbness during childbirth matters, more specifically because gravity helps babies come out, and when the mother is numb, it is more difficult to get into upright positions, but it can be done. Mothers who are numb can still move into hands & knees, semi-squat, and side-lying positions with assistance – but are just unable to move into these positions spontaneously.

Spontaneous movement during labor is actually a comfort measure! Ah ha! But it can’t be used unless a mother is experiencing the sensations of childbirth (unmedicated) and working with those sensations. (This is why I love Hypnobabies as a pain minimization method.)

So of course successful vaginal birth is possible (and quite common) with an epidural, especially if it’s not her first baby and especially if she is assisted into different positions. Sometimes vacuum extraction and forceps are needed to help pull the baby down “manually” if the baby is not descending on its own. Sound fun? (If you thought being upright for vaginal childbirth didn’t sound like a blast, it’s all about perspective.) If the baby is not low enough to begin with, these techniques cannot be used and Cesarean would be recommended instead.

So what is often labeled as “baby is too big to fit” is actually “baby has not descended low enough.”

So we’ve covered the basics of why the baby might not descend low enough: the mother may be unable to help much with pushing. And if it’s her first baby, she’s going to have to help, even in those upright positions, if she is to birth her baby vaginally. And that’s kind of a big if: more often than not, after an epidural is placed, a mother stays in bed and lies on her back or on one side. A good L&D nurse will come back every half hour or so to shift the mother to her other side, placing her top leg in the stirrup to keep the pelvis open. (This disrupts rest, which is one of the main reasons for an epidural, but it’s still necessary.)

(By the way, spontaneous movement and upright positions can also reduce the risk of tearing. Do you know what increases the risk of tearing? Lying flat on the back to push [pushing uphill] and coached pushing [hold your breath, count to 10, and bear down as hard as you can until I say stop].)

What else might prevent a medicated mother from birthing vaginally? Exhaustion. Can exhaustion also become a factor in unmedicated birth? You betcha. However, if we are keeping an unmedicated mother hydrated, energized, mentally encouraged and physically supported, we can keep that exhaustion at bay. (These are the tasks that doulas help with tremendously.) We can also offer her a tub of deep water to relax and soothe her muscles and tissues. All of these things can indeed shorten the time it will take before she has her baby, alert and drug-free, in her arms.

But exhaustion in the medicated mother is also a real concern and here’s why: IV fluids do not hydrate a person in the same way that spontaneous and frequent sips of water and juice do. The IV is a constant drip and enters the bloodstream rapidly. IV fluids must be given to a mother before an epidural is placed in order to decrease the risk of one of the most common side effects: a rapid drop in blood pressure. (Another common side effect of the epidural is maternal fever, which can also cause fever in the baby.)

Exhaustion can also become a factor when using an epidural because of a dramatic slowing of the process. The more time passes without any nourishment (women are only “allowed” to consume ice chips after getting the epidural) or total therapeutic rest (which comes naturally after an unmedicated birth because baby will be alert to feed and will then often sleep a good stretch), the more likely exhaustion is to occur.

What else? If you think the mother’s position is important to help the baby come out, you’re right. But what about the baby’s position? What’s the heaviest part of the baby? The back of the baby’s head. Guess where the back of the baby’s head can swing when the mother is lying down? To the mother’s back. So what happens? The baby may then be attempting to exit forehead first. I’ll give you a clue: the forehead is not the smallest part of the baby’s head. So you can easily see why women are told their babies are too big to fit.

These things do not always happen. I have seen an epidural help speed up dilation rapidly because it has allowed a woman to release all tension in her body. There are absolutely many cases where dilation and descent happen rapidly, the mother is able to push effectively and relatively quickly, and the baby is born without any complications. This is usually because the baby wasn’t exposed to the narcotics within the epidural for very long. So it all depends on timing and the way that each woman’s body responds to what was introduced.

I’m not anti-epidural but I am all for giving women detailed information about reasonable alternatives so that it is within their power to choose and so they can avoid potential complications if they choose to. It can seem like speculation when we can’t predict the effects of medicated birth and whether an epidural will increase the odds of needing a Cesarean birth, however the risk is real and the rights of childbearing women demand that our daughters, sisters, and friends know about alternatives. That’s why drug-free childbirth is a part of the current discussion on women’s empowerment.

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