I enter the labor ward. It has several rooms, and I need to find out which one I am needed in right now. It doesn’t take long at all: behind one of the doors I hear a woman screaming. Every time I think about it, I find it strange: in the twenty first century, the only place left in the hospital where you can be sure to hear screams of pain is in the labor ward.
I open the door, and the situation is pretty ordinary. A woman in her late twenties is sitting on the edge of the bed, holding her abdomen with one hand and her husband’s hand in another. Her face is distorted, she is breathing rapidly. Her husband has the typical look of a helpless person who really wants to help, but doesn’t know how. An older woman – probably the patient’s mother – is sitting on the chair next to the bed. She also looks upset.
The attending midwife (she looks unhappy) tells me the details: “Primipara, five centimeters.”
I introduce myself: “Hi, I am Doctor Smetannikov, I am the epidural guy”. She nods.
I ask the woman:
- Has anybody spoken to you about the epidural?
- Yes, they mentioned it in the prenatal classes.
- Are you happy with the risks?
The contraction starts, and the answer is mixed with a groan:
- Please, doctor, just do it!
When the contraction is over I run through the brief list of serious complications. Epidural can make you paralyzed, though it is very rare, about one in one hundred thousand (erring on the higher side). In about one percent of cases it can result in a headache, which may need another injection in the back to cure it. The risk of sticking the needle in the wrong place, damaging the nerves or spinal cord, the risk of infection, all very low. The woman is listening impatiently and then repeats: “Fine, just do it.”
I put on the mask, wash my hands and dress up in a surgical gown. The procedure takes about ten minutes. I use a combined spinal epidural technique, and pain relief is almost instantaneous: the very next contraction feels much less painful. After the epidural catheter is fixed to the skin with dressings the woman lies down. I administer another dose of local anesthetic through the catheter. Ten minutes later the woman smiles. Slightly bewildered, she turns to her husband, whose mood is visibly better, and says: “Why the hell didn’t we do this earlier?”
I have a chat with the woman. It turns out she planned to have her childbirth the natural way, without drugs or interventions. She heard stories about problems with epidurals and their bad effects on the baby, and decided not to risk it. After all, she was told, labor is a natural process, and a woman’s body is designed to produce babies. When I asked what specific problems with epidurals they told her she is likely to have she shrugs and says: “I don’t know… just problems”.
Labor pain is one of the most intense varieties of suffering the human body is capable of experiencing. Most women agree with this. If you are a man and want to get an idea what labor pain feels like imagine your finger ripped off during an accident, or a needle drilled into your root canal. According to studies, experiences similar to these are closest to the pain of giving birth to a child. Except the latter can last for hours, even days. It also gets worse as the labor progresses.
Many modern medical subjects revolve around pain. In fact, pain is the most common reason of visiting a doctor, and a lot of clinical and laboratory research has been devoted to it. Medicine has made tremendous progress in the treatment of pain, and now we can successfully eliminate or at least significantly reduce pain that accompanies most medical conditions. We can also reduce the pain of childbirth.
However, this is where strange things start happening. There is a large lobby of the proponents of natural birth, who believe that any intervention in the process of childbirth is unnecessary and often harmful. This includes relieving the pain of labor. According to the proponents of natural birth, pain is an integral part of giving birth and is important for the proper course of labor and bonding with the baby. An extreme group of the proponents of this view are the home birth advocates, who believe that childbirth must happen at home, away from doctors and medical equipment.
Before arguing about the role of pain in childbirth, let’s define it. What is pain? In medical textbooks pain is defined as the unpleasant experience associated with actual or perceived damage of the tissues. Pain plays an important role: it indicates to us that something in the body is damaged. As a result, our behavior is modified in such a way as to limit the damage. For example, if you strain ligaments in the ankle during exercise it becomes difficult to continue the activity. Pain forces you to stop and to take care of the ankle and facilitate the healing process. Incidentally, actions that lead to the improvement of pain often help the healing process. In our example, the application of an ice pack to the strained ankle reduces swelling and inflammation. Experience tells us that when we interfere with the protective function of pain, the consequences can be disastrous. One example is when unscrupulous sports medics give injured athletes a local anesthetic injection, so that they can continue to participate in a competition in spite of injury. In many such cases athletes developed severe injures that eventually forced them out of the sport.
Pain in labor also serves a purpose: it signals to the woman that her labor has started and that she now has to take steps to deliver her baby. The intensity of labor pain makes absolutely sure there is nothing else on the woman’s mind. It was very important thousands of years ago: the female ape would have to stop hopping trees or hunting, find a quiet place away from potential predators, lie down and take care of delivering her offspring.
However, times have changed, and I don’t suppose many modern women need a reminder of their childbirth duties. Once the pain starts you head to the hospital – or the birth center, if this is your thing – and let the professionals take care of you.
The proponents of natural birth argue that pain is the natural, inseparable part of a woman’s experience of childbirth and must not be interfered with. Supporters of this view believe that pain triggers physiological mechanisms that improve bonding between mother and baby. As far as I am aware, however, there is no evidence to support this opinion. Do you think epidural is going to make you love your child less? How come fathers love their children, even though they never feel the pain of labor? What about all those babies born via elective cesarean section, are they all unloved and abandoned? This, of course, is complete nonsense.
Finally, some believe that intervention in the process of childbirth is simply not necessary. Hundreds of millions of women gave birth before modern medicine started interfering with labor and labor pain, what’s the problem? In Africa women still give birth like in the olden days, and the population of that continent keeps increasing.
Those who believe in “good old times” ignore the facts of evolution. I am not even touching the fact that the rate of death among mothers and newborns in pre-modern medicine times was high (as it is in the countries with under-developed healthcare). Most importantly, modern humans are not the same animals as they were even a couple of hundred years ago. The food we eat is very different from what our ancestors consumed thousands of years ago. This food is also more available, and we don’t have to hunt it. In fact, we have to spend very little energy getting it. We live in warm houses, get around in cars and public transport, and are vaccinated against serious infections. Hell, we do just about everything differently from our not so remote ancestors. Modern women have modern jobs and pursue business careers, and their lifestyle is as different from that of primal humans, whose ability to effortlessly deliver babies is so romanticized by the believers in the natural birth.
If you think of it, a large part of population in the developed world is probably not supposed to be alive. Before the wide use of cesarean sections, every obstructed birth would end up in the death of the neonate. Now we can save these babies. However, they carry with them the genes that increase the risk of problematic labor in the future, either theirs or their children. If my mother had problems delivering me, am I wrong to predict that my daughters are more likely to have problematic labor when their time comes? The fact that both of them were born via cesarean further reinforces my prediction.
There are many diseases that would reduce the chances of survival even several decades ago that science found ways to cure. Thanks to modern medicine, the survivors of such diseases can conceive and safely deliver children.
It is impossible to say with certainty to which degree these conditions affect pregnancy and childbirth. However, there is no denying that there is at least some influence of the modern lifestyle on the process of giving birth.
The idea that pain is natural is seriously flawed. For some reason the suggestion of giving birth without pain relief seems reasonable. What about surgery? Would you have your gallbladder removed without an anesthetic? Would you feel that you have achieved more if you experienced the full impact of the pain during the operation?
However, my opinion in regards to the pain of childbirth is only that: an opinion. While the idea of experiencing unnecessary pain seems silly to me, the choice is not mine. Women have the right to decide on the course of their labor. Personally, I am all for choice. Pain can be enjoyable (sort of) in some situations. During my anesthetic training in South Africa, several of my friends were running marathons, some of them taking part in the world famous ultra, Comrades Marathon. For the uninitiated, “ultra” means a distance longer than the standard marathon, which is about 26 miles (42 km). The Comrades Marathon is twice that distance, which is over 50 miles. I get tired driving that far, but I understand people who participate in such an event. The feeling of achievement after finishing the distance after several agonizing hours must be unbelievably uplifting.
To run or not to run the Comrades is your choice, unless you are a professional runner whose salary is paid by some sponsor. You don’t have to run it if you choose so. You can stop any time and call someone to pick you up, go home and watch the rest of the race on TV.
In childbirth choices are limited. Once you decide to have a child and fall pregnant there is no way back: the baby has to come out, be it vaginal birth or a cesarean. First time mothers have no idea what is ahead and have to rely on the experience of their friends or family members. This is not terribly helpful, as our perception of pain and suffering is different. Ask ten women about their childbirth pain. Some will say it wasn’t so bad, while some will rate the experience as horrible. Who do you trust?
Unfortunately, the experience is unreliable. Pain is personal, and the degree of suffering acceptable for one person may feel like the end of the world to another. The perception of pain is influenced by many factors, such as previously experienced pain, ethnicity, education, expectations, support of the husband and the family, and many others.
The question however, is not whether pain of childbirth is bad or not, but what you want to do about it. The first step to prepare for labor is to learn about it and understand what happens in the body during the process and what causes pain. Then you can learn about the various interventions and what to expect from them, both in terms of benefits and risks. There are various methods and techniques that may be helpful in reducing labor pain, from doula support and hypnosis, to injections of drugs and epidural blocks. Each carries risks and benefits, and, unfortunately, more innocuous methods also tend to be less useful.
The strongest argument that seems to tip many women away from the epidural is potential harm. Epidural analgesia is an invasive intervention that involves sharp needles and drugs and may cause complications, both for the mother and the baby. While this is true, the chance and the magnitude of possible complications is often greatly exaggerated by those who want to discourage the woman from this way of pain relief. And this is where I have a problem.
Life is filled with risks. Driving a car, taking a dip in the swimming pool, going for a walk in the forest or playing soccer is risky to some extent. People have been electrocuted while operating kitchen appliances. Will you have second thoughts about using your blender? I suspect not, probably because the risk of dying from a blender is very low. What about epidural? In short, the risk of labor epidural is also low. Actually, very low. The magnitude of various complications also varies. Returning to the example of risks taken in the kitchen, complications of using a kitchen knife potentially range from a minor finger cut to death. The former is relatively common, while the latter is very rare. Similarly, the most common side effects and complications of epidural are not serious and often are more of an inconvenience that is easy to correct, rather than a health hazard. On the other hand, serious though rare complications, such as paralysis following labor epidural for example, are more likely to be reported in the press and become sensationalized. The understanding of complications and probabilities of developing them is absolutely crucial when deciding on the method of pain relief in labor.
One of the most amazing things I find over and over again is that everyone seems to know what’s best for a pregnant woman and her baby. In the opinion of the idealists the perfect childbirth must be accompanied only by a midwife and must not involve any drugs. If you cannot cope, well, some “happy gas” is acceptable. The next step on the sinful path of assisted childbirth is an injection of an opioid, meperidine (pethidine) or morphine. Not all is lost, however, until you give in to the final temptation: the epidural. That is the real failure… Of course, there is one more step towards doom: the caesarean. But even when it comes to surgery, the birth idealists cling to the remains of the idea of natural childbirth: getting spinal block for the cesarean and staying awake is better than caesarean under general anesthesia.
There is one thing that you, as an expectant mother, must understand: there is no ideal childbirth. Everyone is different, and whatever you choose for your labor is nobody else’s business. It is your body and your baby. You don’t have to meet the expectations and beliefs of people around you, either the members of the family, midwives or doctors. Your ultimate goal is to get through labor with minimal chance of complications for yourself and your baby. You are not a Spartan warrior, and it is ok to be afraid of pain. It is ok to ask for an epidural early in labor, when the pain is still bearable. If you don’t like the idea of vaginal birth then choose an elective caesarean. The achievements of modern medicine are such that every option of childbirth is very safe. Look at people around you. Can you guess who was born by caesarean section or whose mother had labor epidural? If not, then the dangers of both are seriously overrated.
This purpose of this site is not to “sell” you labor epidural. The purpose of this work is to explain what epidural is and its risks, based on statistical data, as well as clinical research and experience. You will also learn that labor epidural carries benefits, for the mother, as well as the baby.
In the last several decades the practice of relieving labor pain has changed a lot. New drugs and techniques have been introduced. The complications and side effects have been thoroughly researched and summarized. As the title of this website says, its purpose is to tell the readers all about labor epidural. I hope you find it helpful in making your decisions as to what pain relief you choose for your labor.
Dr. Eugene Smetannikov