Epidural Injections for Childbirth Rising

Review Shows Pain Control Procedure to Be Safe, Effective

Jan. 22, 2003 -- More and more these days, women are opting to avoid the pain of childbirth by having epidurals. Some 60% of women giving birth in the United States now have the anesthetic infusions during delivery, compared with roughly half that number a decade ago.

Although there are still concerns about the effects on mother and baby, a new review shows epidurals to be a safe and effective means of pain relief during labor. And death rates in women having cesarean sections have plummeted in recent years, largely because they now routinely receive epidurals instead of general anesthesia.

"Epidurals have become very popular because they work so well," study co-author and obstetric anesthesiologist William R. Camann, MD, tells WebMD. "The epidural that is given today is likely to be very different from that given 10 years ago. There have been a lot of refinements that have resulted in better pain control with less immobility."

A basic epidural involves the infusion of anesthetic in the epidural space (the space between the spinal bone and the spinal cord) surrounding the lower spinal cord.

In their review, published in the Jan. 23 issue of TheNew England Journal of Medicine, Camann and colleagues at Boston's Brigham and Women's Hospital address some of the most controversial issues surrounding epidurals. High on the list is the claim that the procedure is associated with a higher rate of cesarean deliveries.

Camann, who is director of obstetric anesthesia at Brigham and Women's, says it is clear that epidurals do not influence C-section rates overall. But they may affect rates among a subset of women -- namely, those giving birth for the first time who are also experiencing long labors.

"The best evidence we have suggests there is no association, even among these women, but the studies are not conclusive," he says.

The researchers also reviewed studies looking at length of labor and instrument-assisted vaginal childbirth. The instruments, forceps and vacuum extraction devices, are used to help guide a baby's head through the vaginal canal. One review found that the rate of instrument-assisted delivery was double when epidurals are used. The evidence also suggests epidurals prolong labor by an average of one hour.

According to Camann, the biggest unanswered question surrounding epidurals is why certain women develop elevated temperatures several hours after having epidurals. The phenomenon is confined to first-time mothers who are still in labor five or six hours after the procedure is done, he says.

The authors write that the abandonment of general anesthesia in favor of epidurals among women having both emergency and routine C-sections may be the most important reason for the decrease in anesthesia-associated maternal mortality. The latest study to track those rates found a drop in anesthesia-related childbirth deaths from 4.3 per million to 1.7 per million cases.

The growing popularity of epidurals suggests an abandonment of the natural childbirth movement, which stressed drug-free deliveries and saw its heyday in the 1970s and 1980s. But longtime midwife Lisa L. Paine, CNM, DrPH, says it instead reflects the fact that women are not being given the information they need to make informed choices about pain medication during childbirth.

"Some women do need epidurals, just like some need C-sections," she tells WebMD. "Unfortunately, there are a huge and growing number of women who think epidurals are part and parcel of the childbirth process. It is not as if they even view this as a decision that they need to make."

Show Sources

SOURCES: The New England Journal of Medicine, Jan. 23, 2003 • William R. Camann, MD, director of obstetric anesthesia, Brigham and Women's Hospital, Boston • Lisa L. Paine, CNM, DrPH, midwife, public health consultant, Hutchinson Dyer Group, Cambridge, Mass.
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