The Truth About Epidurals: What You’re Not Always Told About Birth Choices

We explore epidurals in childbirth, examining what they are, their risks, and why unmedicated birth options deserve equal consideration in your birth plan.

• Epidurals are regional anesthesia using local anesthetics and opioids to block pain signals from the waist down
• Research shows epidurals can slow labor progression, especially during the pushing phase by up to 90 minutes
• Associated with higher likelihood of requiring vacuum extraction or forceps during delivery
• Can contribute to a cascade of interventions including Pitocin, continuous monitoring, and potentially C-section
• Side effects include maternal hypotension in 14-33% of cases, which can reduce blood flow to the placenta
• Rare complications include post-dural puncture headaches and nerve damage
• Can cause maternal fever (15% higher risk), potentially leading to unnecessary antibiotic treatment for baby
• May affect baby's alertness and rooting reflexes, creating challenges with early breastfeeding
• Despite risks, epidurals have benefits including pain relief, stress reduction, and making complicated labors manageable
• Create a "moment of crisis plan" to determine your first step when you need help during labor

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Links to research: 

Epidurals effect on second stage of labor -https://pubmed.ncbi.nlm.nih.gov/24499753/

Epidurals effects on vacuum or forceps use in birth -https://pmc.ncbi.nlm.nih.gov/articles/PMC6494646/

Reducted risk of cesarean delivery with discontinuation of pitocin in active labor   - https://www.ajog.org/article/S0002-9378(25)00161-9/fulltext

Epidurals and maternal fever -  https://www.ajog.org/article/S0002-9378(22)00480-X/fulltext

Epidurals and early breastfeeding difficulty -  https://www.ncbi.nlm.nih.gov/books/NBK501222/

Chapters

• 0:00 Introduction to Epidurals
• 1:12 How Epidurals Work
• 2:14 Risks and Side Effects
• 5:28 The Cascade of Interventions
• 9:05 Making Informed Choices
• 12:49 Episode Wrap and Resources

Transcript

Deborah: 0:06

Hey Mamas, you're listening to Tend and Befriend, a podcast about women's mental and physical health. This is Debra. I'm a mom of two, a labor and birth coach and birth advocate, a health professional, and today I'm your host. Let's dive into today's episode. Your host, let's dive into today's episode. Any information you hear or that is suggested or recommended on these episodes is not medical advice. Hello and welcome to Tend and Befriend, the podcast where we explore evidence-based topics in pregnancy, birth and postpartum with honesty and compassion. I'm Debra, your doula, your host and childbirth educator, and today we're discussing a topic that comes up in almost every birth preferences conversation Epidurals.

Deborah: 0:55

What are they, what are the risks and why is birthing without an epidural often not even discussed? Let's unpack it all. Let's begin by saying that an epidural is a form of regional anesthesia commonly used during labor to block pain from the waist down. It's administered through a catheter placed in the epidural space around your spinal cord, in the lower segment of your lumbar spine. The medications used in an epidural typically include a combination of lidocaine or bupivacaine, which are local anesthetics that block pain signals, and fentanyl or sufentanil, which are opioids that enhance pain relief. The goal of these combination of drugs is to numb the lower half of the body while allowing you to remain awake and aware during labor. Epidurals can provide much needed relief for many birthing people, but they're not without risk and considerations. While epidurals are widely regarded safe, they do come with potential risk and side effects. So let's talk about those risks.

Deborah: 2:04

Research has shown that epidurals can slow the progression of labor, especially during the second stage, which is the pushing phase, and this happens because epidurals reduce the sensation and relaxation of the pelvic floor muscles, which can then interfere with baby's descent. A study published in Obstetrics and Gynecology in 2014 found that epidurals increase the average length of the second stage of labor, the pushing phase, by up to 90 minutes. Wow, that's a long time For some birthing people. This can increase the need for additional interventions. It's like a ball rolling downhill, like Pitocin to augment the contractions ball rolling downhill, like Pitocin to augment the contractions. Epidurals are also associated with a higher likelihood of requiring vacuum extraction or forceps during delivery. The Cochrane Database of Systemic Reviews actually did a really amazing report in 2018 that said that women with epidurals are more likely to require instrumental delivery, such as vacuum or forceps. This increase basically and the study suggests this that it's to do with the weakened pushing efforts due to the reduced sensation and the coordination of your abdominal muscles and your pelvic floor during that second stage, the pushing phase of labor.

Deborah: 3:24

While modern research suggests that epidurals themselves don't directly cause C-sections, they can contribute to a cascade of interventions that increase the risk. For example, if labor slows significantly because of an epidural and Pitocin doesn't help, then a cesarean section is necessary. In 2011, the American Journal of Obstetrics and Gynecology highlighted that epidurals contribute to longer labors, which can lead to interventions like Pitocin, which is the artificial hormone oxytocin, ultimately increasing the risk of cesarean delivery if labor does not progress as expected. A JAMA pediatric study done in 2014 found that when epidurals are administered early in labor, before four to five centimeters dilation, which is typically around the active labor phase, the risk of cesarean delivery increases compared to later administration, basically saying time your epidural to after you are in active labor.

Deborah: 4:25

Epidurals work in that they block sympathetic nerve activity, which can cause maternal hypotension when mother's blood pressure drops. According to American Society of Anesthesiologists, approximately 14 to 33% of epidural recipients experience a significant drop in blood pressure. That's a pretty big percentage and that can feel really, really crappy when you're trying to give birth. This hypotension can reduce blood flow to the placenta, of course, leading to transient drops in the baby's heart rate, otherwise known as fetal bradycardia. And guess what happens when baby's heart rate drops significantly in labor? What? Boom, boom, we got to get that baby out. That is usually the instinct. They watch for a little bit. But because you have an epidural and that's a continuous flow, then that baby's heart rate is going to most likely continue to be affected. That is why continuous monitoring of the baby's heart rate is absolutely required after an epidural is placed here in Canada.

Deborah: 5:38

In rare cases with an epidural the needle that is placing the catheter of the epidural it can puncture the dura, which is the membrane surrounding the spinal cord, leading to a significantly severe headache known as post-dural puncture headache, and long-term complications can include back pain or nerve damage. Post-dural puncture headaches occur in 0.5 to 2% of epidural cases due to accidental puncture of the dermator. This condition is well documented in regional anesthesia and pain medicine. If you are really curious about that, I suggest that you go read that article. These headaches are severe and may require a repair called a blood patch where blood is injected back into the epidural space to seal that puncture that happened from the placement of the needle. I've had this happen a few times with patients in my clinical care and the healing time with this injury is long and hard and, of course, you're going home with a baby and you're suffering from these extreme headaches. It is not a very pretty picture and I feel so much for those moms who have gone home with this.

Deborah: 6:50

Epidurals can sometimes cause maternal fever, which may lead to unnecessary antibiotic treatment for the baby after birth. So with epidural placement, sometimes women end up with a fever and then that leads to the ball rolling into antibiotic treatment for the baby. A 2000 study in anesthesiology found that women who received epidurals had a higher rate of maternal fever. That increased risk is approximately about 15%, which means you have a 15% higher chance of developing a fever if you get the epidural. This fever may lead to neonatal sepsis workouts, requiring your baby after birth to undergo blood tests or even antibiotics unnecessarily. A study published in Birth in 2011 suggested that epidural medications, particularly opioids like fentanyl, can affect the baby's alertness and rooting reflexes, leading to challenges in early breastfeeding, which we have seen quite a bit in the birthing world.

Deborah: 7:52

Epidurals are considered the norm in many hospitals, with over 60% of laboring people in Canada opting for one. But here's the thing many childbirth educators who work within the hospitals don't even discuss on medicated birth options. Why? Because they view epidurals as the default. The normalization of getting an epidural often leads birthing people unaware of alternative pain management like movement, water immersion, breathing techniques, massage, nitric oxide. Any of those other options sometimes can be skipped over because all that we're informed of is the epidural. It also perpetuates the idea that labor pain is something to be avoided at all costs rather than a natural, manageable part of the birthing process.

Deborah: 8:40

Now let's be clear. I believe that epidurals have their place and can be a game changer for many birthing people. For example, epidurals can provide relief from intense labor pain, allowing you to rest and conserve energy for the pushing phase. Epidurals can lower stress levels, which can sometimes help labor progress if your mama's body is just so tense and is not relaxing at all. No matter what you do, epidurals can be a lifeline in prolonged or complicated labors, making the experience more manageable and non-urgent or emergent. For some people, an epidural is the absolute right choice, and that is absolutely okay. The issue with epidurals itself, it's the lack of informed choice and the over-reliance on it as the default. One of the biggest concerns with epidurals is the potential for a cascade of interventions and that ball.

Deborah: 9:38

Once it's moving, it's hard to stop it. And here's how that can play out You're in labor, you can't take it anymore. It's going well, progressing well, but you're not coping well with the contractions. So you get an epidural. You're able to rest. Epidural slows down your labor. And then we're faced with a decision. So then the first thing that happens typically is they will administer Pitocin to strengthen your contractions because labor is stalled or slowing. To strengthen your contractions because labor is stalled or slowing, then Pitocin leads to stronger, more painful contractions. And then you need more epidural and also stronger contractions, increased fetal distress requiring continuous monitoring, and if labor doesn't progress, a cesarean delivery is automatically on the table. It's one thing after another until it becomes a cesarean section. Now, this isn't to say that every epidural leads to this outcome, but it's a pattern that childbirth educators and doulas see often in hospital settings.

Deborah: 10:42

The key takeaway here is that epidurals are neither inherently good nor bad. They're a tool. The question is whether you're being given all of the information and all of the options to make an informed decision. Here's what you can do. You can ask questions If your provider suggests an epidural, ask about the timing, alternatives and potential risk. Consider your birth plan, think about how you want to manage labor pain and discuss this with your care team ahead of time.

Deborah: 11:13

I like to talk about a moment of crisis plan. So, basically, what are we doing when I first need help? Is it the epidural? If it is, go for it. If that isn't your first choice for the first crisis, play all of those steps first. Is it getting in the shower? Is it movement? Is it using nitric oxide? Is it asking for some Demerol? What is that first step when you first ask for a little bit of help? So those things are what we talk about. When you consider your birth plan.

Deborah: 11:41

Then we're going to explore non-medical options. Learn about techniques like breathing, exercise, water birth or using a doula for additional support. Now, when I talk about explore non-medical options, that really depends on the birthing center that you've chosen either the hospital at home or an actual birth center. Some of these things are not an option in every one of those places. You also want to advocate for education, push for childbirth classes that present all options equally and are coming to you on bias, including an unmedicated birth, if that is something that you are tossing around, or even if it's advocating for the fact that you do not want an epidural until this moment in time or at this centimeters of dilation.

Deborah: 12:30

That's a wrap for today's episode of Tend and Be friend, I hope this conversation about epidurals has helped you feel more informed and empowered to ask what you need to ask, and remember the goal isn't to say yes or no to an epidural. It's to make a choice that feels right for you and for your family, and for this birth specifically. Also, as an Amazon affiliate, I earn a small commission if you purchase through my links, but this doesn't affect the price you pay. These commissions help support this podcast and that allow me to keep sharing all the free resources with you. I only recommend products that I genuinely believe in and trust. Thank you for all of your support. If you found this episode helpful, please share it with a friend, leave a review or subscribe for more evidence-based discussions on pregnancy and birth. Until next time, take care and keep nurturing yourself and your village. Let's talk soon. Talk to you soon. Okay, let's talk soon.