Childbirth study finds lesser risk in epidurals

For years, many women in labor have endured hours of excruciating pain because doctors warned that early use of epidural anesthesia could increase the likelihood of a Caesarean section, a surgical delivery that carries some health risks to the mother. But a new study says that the advice is wrong and that women need not suffer.

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Although 60 percent of the approximately 4 million women who give birth in the United States every year receive epidurals, obstetricians disagree about when it is safe to administer, especially for first-time mothers. Under recommendations adopted by the American College of Obstetricians and Gynecologists in 2002, a first-time mother's cervix should be dilated at least 4 centimeters -- nearly halfway to the 10 centimeters needed for a normal delivery -- before an epidural is administered.

Doctors at Northwestern University challenged that guidance in a study published in today's New England Journal of Medicine, in which women given an epidural before they reached the dilation threshold had faster deliveries, better pain relief, and no more C-sections than women who received narcotics. Narcotics are commonly given to women to dull pain early in labor but are not as effective as an epidural, a local anesthetic injected into the membrane around the spinal cord that blocks pain from below the waist.

Efforts to reduce pain in childbirth have long been controversial -- midwives who offered pain relief were burned at the stake in the 15th century. More recently, concerns over the effects of anesthesia on the infant and opposition to the medicalization of childbirth -- which until the last century took place at home -- led to support for "natural" childbirth, which relies on relaxation techniques and other methods to help women deal with pain. But as anesthesia has become safer, the natural-childbirth movement has waned.

"Women basically just get a lot of messages that [labor] is hard to experience . . . and then they may meet some people who can say they do it without [medicine] and it will be better for you, or the opposite. And they feel a certain pressure," said Carol Sakala, director of programs at the New York-based Maternity Center Association, a nonprofit group. She said a recent study showed that an increasing number of women are getting epidurals.

With all the mixed messages, "what happens is really women come into labor unprepared for the pain," said Dr. William Camann, an anesthesiologist at Brigham and Women's Hospital and author of an accompanying editorial in the journal. "This study certainly adds a lot of reassurance to those who want to have epidurals earlier on in labor."

Studies in the early 1990s showed that women who received epidurals early in labor, before their cervix had opened much, had higher rates of C-sections than women who did not. Doctors believed that the epidural might be interfering with the uterus contracting properly. As a result, obstetricians widely began giving women who requested early pain relief narcotics.   Continued...