Epidurals - The Cascading Effect of Epidurals
By Charles S. Mahan, MD, FACOG
The abundant use of epidurals today always seems ironic to me. I've been in obstetrics for over 30 years and when I began training, it was impossible to get an anesthesiologist to come up to the obstetric floor to help us out. There were several reasons for this. First, there was a big shortage of anesthesiologists. Second, the anesthesiologists didn't like to be up at night for something that didn't pay too well. And, third a lot of them just weren't trained in obstetric anesthesia. This has changed dramatically and now there are many anesthesiologists. As a matter of fact, we sort of joke that if you're not careful, one may jump out from behind the examining table at the first prenatal visit and pop an epidural in you and you will have one for your whole pregnancy.
For many years we debated (argued?) with anesthesiologists that epidurals slowed labor. Now there are many, many excellent studies in the obstetric and anesthesia literature showing that, indeed, in a significant number of people, labor is slowed by epidural anesthesia. The trouble is that you can't predict very well ahead of time whose labor is going to be slowed and whose isn't. I feel that the best way to approach this is to try very hard to get through labor without an epidural.
Certainly, an epidural is very nice to have for the patient who decides that everything else has been tried and she really needs some serious kind of pain relief. However, we must look at what can happen if epidurals are put in too soon in labor or in the wrong person. We can't select the right person necessarily. The epidural may slow down her labor, sometimes stop labor. When this happens the woman may have to receive Oxytocin, a drug that she otherwise would not have needed. The Oxytocin makes her contractions more painful if the epidural is not complete and doesn't block out all of her pain. Having been confined to bed, she can't walk around anymore which is one of the best cures for a slow labor. She may be encouraged to push before the head has completely dropped down into the pelvis to a +2 or +3 station. Pushing too soon, as we know, can lead to severe dystocia and increases the risk of cesarean section. We know the risk of operative delivery with the use of epidurals, both cesarean section and forceps delivery, and episiotomy is much higher.
Sometime all of these effects are not presented to the patient as the good and the bad. I think that it is very important that the positive and negative effects of an epidural be presented. Epidurals are wonderful for the person who may need them, but the price that one pays has to be carefully considered before they're chosen.