Epidurals do not in themselves improve birth experiences
OPINION: Epidurals may slow down a birth and are associated with lower levels of satisfaction with the birth experience. While sometimes necessary, we are skeptical of the extent to which they are offered and used.
It is well recognised that a positive birth experience is important for childbearing women.
Several studies have reported that women can experience intense pain during labour and at the same time great achievement and report their birth experience as good (“…this hurts, but it also feels awesome”). This paradox is called “the dichotomy of great pain and great joy in normal childbirth”.
During childbirth, the pelvis and birth canal expand, tissue stretches and is dilated, which is painful. Fear and insecurity can make the pain more intense.
From an evolutionary point of view, labour pains are useful. When the pain sets in, the woman knows that she is about to give birth and can get to a safe place. If the baby just popped out with no warning, it might be born somewhere where the mother was alone and unprotected, and could easily fall prey to predators. This is not a problem in this day and age, but it would be inconvenient to realise that you're about to give birth in the checkout line in the supermarket.
Assistance ensures survival
Assistance during childbirth ensures survival, and this was the case long before we had midwives, doctors and hospitals. A woman in labour pain appeals to our instinct to help, and the other women would gather round to comfort, encourage and offer help.
The human is the only primate that needs and wants help when giving birth. Because we have developed into a species with a large brain and walk upright, there is only just enough room for the baby to pass through the birth canal. In addition, the human child is immature and helpless at birth.
The great apes do not have the same problem. A female gorilla, for example, prefers to give birth alone, but then she has a far easier time than we do. She weighs 100 kg and is 140 cm tall, moves around on all fours, has a spacious pelvis and gives birth to a 2-kg baby. The whole thing is relatively straightforward.
The benefit of natural birth hormones
Now, is it necessary to experience pain during labour in 2020? No, it is not. An epidural anaesthesia can remove the pain.
It is widely used in Norway– 41 per cent of all women in labour had an epidural in 2019. Epidurals were most common in the county of Oslo (52 per cent) and least used in the northern county of Troms and Finnmark (28 per cent).
Isn't it great that women can give birth without pain? Yes, it is vital for some women to have an epidural. But we are sceptical of the extent to which this form of anaesthesia is offered and used.
Several hormone systems support and facilitate labour onset, the birth, breastfeeding and bonding through complex interactions.
The hormone oxytocin has several well-known effects during labour and birth: it causes contractions, has calming and analgesic effects on mother and baby, promotes breastfeeding, the attachment between mother and baby and reduces maternal blood loss. It may also protect the baby’s brain during birth and play a role when the baby’s guts is introduced to thousands of species of microorganisms during and after birth.
Physiological birth with its hormonal influence is probably beneficial both for the baby and the mother. Interventions such as caesarean section, induction of labour, use of synthetic oxytocin and epidural are beneficial in many circumstances, but may also have adverse effects. Epidural anaesthesia may lower the production of the birth hormone oxytocin and slows down labour. Most women with an epidural receive an intravenous infusion with synthetic oxytocin to speed up labour.
Pain relief is not the most important
There is nothing to indicate that epidurals in themselves improve the birth experience. On the contrary, the research available indicates that epidurals are associated with lower levels of satisfaction, or at best, does not influence the birth experience. Remember that while this is true at a group level, it will not be true for every individual woman.
One possible reason for this finding is that women who did not have an epidural, and managed the labour pain, are left with a greater sense of accomplishment. Another likely reason is that the birth hormone oxytocin improves our ability to cope with pain and stress, and reduces the memory of pain. Finally, pain and pain relief does not seem to be an important factor for the birth experience. Feeling safe, receiving emotional support, individual and respectful care are more important for a positive birth experience.
Thus, labour pain cannot be understood in the same way as pain resulting from, for example, gallstone surgery or a root canal. You cannot, (unfortunately), simply remove the pain and expect the rest of the labour process to proceed as normal. The mother's oxytocin levels are lowered by the epidural, and synthetic oxytocin will usually be administered. Synthetic oxytocin is not as effective as the natural kind.
May impair baby’s instincts
Both epidural anaesthesia and synthetic oxytocin during labour may impair the baby’s instinctive behaviour like suckling and moving towards the breast immediately after the birth, and may affect breastfeeding negatively at a longer term.
Just after birth, the mother releases an oxytocin boost that raises the hormone level in her blood. This has an effect on the mammary glands and promotes breastfeeding, helps the uterus to contract, thereby minimising bleeding, influences the woman's behaviour and attention to the child, and promotes attachment between mother and baby.
If the mother had an epidural, she will usually not experience this peak in her oxytocin level. After the birth, skin-to-skin contact mutually regulates oxytocin systems in both mother and baby, reduces newborn stress and promotes breastfeeding. Early and unrestricted skin-to-skin contact between mother and baby may modify adverse effects of physiological labour disruption.
Childbirth is hard work
We are not trying to belittle labour pains or women who wish to have an epidural. Labour is hard work, and sometimes made complicated by the baby being big, in an abnormal presentation, or the labour taking a long time.
In Norway we all remember the historical novel set in the Middle Ages about Kristin Lavransdatter, who was in labour for several days and whose heart-wrenching screams could be heard all over the farm. We don't want to go back to that.
When pain and fear dominate the situation, the body releases stress hormones that prevent the birth hormones from doing their work. In such situations, good pain relief is important, and an epidural is the most effective way of relieving the pain. Other measures that can help women to manage labour is if the mother is well prepared, if she has someone with her who knows and loves her, that the midwife is present throughout the labour, and that the mother is given practical assistance, emotional support, encouragement and comfort.
The preferred strategy should be managing rather than removing the pains of labour. At the same time, we must ensure that those who need it, or want it, are given an epidural or other form of pharmacological pain relief.
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