Epidurals - The great debate for and against

How does a completely pain-free labour sound? For many mums-to-be worried about giving birth and how much it’s going to hurt, it’s probably an appealing idea. And if Dr Gilbert Grant from the New York University Langone Medical Center gets his way, having your baby without so much as a twinge may not be as impossible as it sounds. 

In his new book Enjoy Your Labour: A New Approach To Pain Relief For Childbirth (£7.99, Russell Hastings Press) Grant argues that all women should be given an epidural before contractions start in earnest and that we should stop fearing – and feeling guilty about – opting for pain relief. Yet many people would argue giving birth is a natural event and women should opt for as little medication as possible.

So which theory is right? Should we really stop striving for a natural, unmedicated childbirth? Or is an epidural the cheat’s way out? We spoke to experts on both sides of the argument and asked them to share their views on the ‘best’ way to give birth.

FOR epidurals

Dr Gilbert Grant, associate professor of anaesthesiology at New York University Langone Medical Center and author of Enjoy Your Labour: A New Approach To Pain Relief For Childbirth (£7.99, Russell Hastings Press)
‘It’s every woman’s right to decide the type of pain relief – if any – she’d like to have during labour and when she’d like to receive it. But what I find so unfortunate is that many mums-to-be don’t make informed decisions because they simply don’t have access to the information they need.

‘In many instances, natural birth supporters, who have a bias against modern pain relief, try to convince women that it is at best unnatural and at worst dangerous to have an epidural, which personally I think is cruel. In the US over 70% of women have epidurals and although more than 150 years have passed since the first anaesthetic was given during childbirth (in Scotland), many people continue to believe women are meant to experience pain.

‘Of course there are always risks with any anaesthesia, including epidurals, but the most common side effect is a headache, which affects one per cent of cases, and for the overwhelming majority of women and their babies, epidurals are a safe, pain-free way to give birth. Yet despite this, many women still suffer through the experience, primarily out of fear, guilt and ignorance.

‘My goal in writing my book has been to tell women the facts about modern pain relief and demystify the techniques in use, in order to help them decide whether they want to make use of these medical miracles during their delivery.
‘And if a woman decides she wants an epidural to relieve the pain, why wait until that pain becomes unbearable? After all, you wouldn’t let your dentist start drilling your teeth without a local anaesthetic! My prediction is that in 30 or 40 years, getting an epidural before the pain begins will be routine practice, and people will think that you’re mad if you don’t.’

‘Epidurals shouldn’t be a lottery based on your postcode’
Dr Maggie Blott, consultant obstetrician, University College London Hospital
‘Epidurals should be more freely available to all women going into labour in the UK. Mums-to-be need good education during their pregnancy so they know what’s available and then their choice of pain relief should not be limited by the hospital they are at, as it frequently is.

‘Epidurals provide reliable pain relief and, in certain situations – if a woman is having a very long labour, for example – they can be especially fantastic as they allow a mum to rest while giving her baby time to descend the birth canal. I actually find that lots of women who have epidurals deliver beautifully, better than women who are in pain, as they’re in control and can take their midwife’s advice during the pushing stage, which decreases their risk of tearing.

‘There are many arguments for having epidurals in the right situation, so while I think Dr Grant’s view may be extreme, I do agree that they should be much more available. At the moment it’s very much a postcode lottery but every single labouring woman should have access to an epidural if she wants one.’

- Visit Netdoctorbirthguide at Dr Foster and enter your postcode to find out about the birthing services in your area. You can even see how many births in your area involve epiduarals.

Dr Cynthia Wong, chief of obstetrical anaesthesia, Northwestern University Feinberg School of Medicine, Chicago
‘The decision to have an epidural is a personal matter. But if a mum-to-be is planning on using full pain relief and understands the risks and benefits, there is no reason why she shouldn’t get an epidural in early labour.
‘There are definite benefits to epidurals – not only that they provide much better pain relief, but other methods, like pethidine, can cause sedation in both mum and baby, plus nausea in the mother.

‘While there are, of course, side effects involved with an epidural, I think for most women the advantages far outweigh the risks. And giving epidurals earlier in labour, as Dr Grant is suggesting, means they’re easier to administer (for the simple reason it’s easier to sit still when you’re not in severe pain) and recent studies have shown they’re also associated with faster labours.
‘This whole discussion, however, is rather ironic in light of the fact that many women are now choosing elective caesareans. The risks of this major abdominal surgery are much higher than those of an epidural and we should therefore be concentrating on educating women about these risks, rather than worrying about whether they opt for a relatively risk-free form of pain relief.’

‘Why put yourself through all the pain if you don’t have to?’
Rebekah Scott, 34, from Stotfold, Hertfordshire, mum to Alfey, five, and Joss, three
‘Having a baby isn’t a competition to see how much pain you can take, so why do women labour in agony when there are drugs that can make it stop?

‘I couldn’t have got through my second labour without an epidural. I’ve never known pain like it. Just five hours in I was only 1cm dilated and begging for pain relief. Joss was in the OP position (which means his spine was against mine) and it was so much more painful than my first labour. By the time the anaesthetist arrived my whole body had gone into shock and I was shaking.

‘Why women who’ve had pain relief think they’ve failed is beyond me. Surely just by having your baby safely you’ve done the most amazing thing – why would you stay in agony, just so you can tell your friends you had no pain relief? That’s insanity. It’s like agreeing to have your appendix out but saying, “No, thanks, I’ll skip the anaesthetic.” If I was pregnant again and I could pre-book it for the minute I went into labour then there’s no question about it, I’d have an epidural every time.’

AGAINST epidurals

‘Women need the facts to make an informed choice’
Dr Alan McGlennan, lead labour ward anaesthetist, Royal Free Hospital, London
‘The idea of giving all women an epidural early in labour is flawed on many levels.
‘Firstly, not every women needs an epidural. In the Royal Free only about 40% of labouring women opt for one, so to give them to everyone would therefore mean a considerable increase in the number administered and, correspondingly, a rise in the side effects. The most common side effect is backache, which occurs in one in three cases, and around one in 200 women suffers a post-birth headache.

‘Secondly, Dr Grant’s theory removes the option of patient choice. One of the reasons the National Childbirth Trust (NCT) was created in 1956 was because people felt their childbirth had become too “medical” and the NCT was devised to provide clear information and put mums back in control of how they gave birth. Dr Grant is arguing that things have now been taken too far the other way, and claiming because birth has become less medically based many women feel they’ve failed if they accept pain relief.

‘My feeling is that pregnant women should be given all the relevant facts about natural childbirth and also what pain relief is available to them. Then they can make an informed decision during labour. Who can tell mums what pain relief they’ll need until they’re actually in pain? Certainly not their doctor. Not even the mum will know until she is experiencing it herself.’

‘We need to get back to basics, not give more drugs’
Dr Michel Odent, obstetrician, researcher and author of 11 books on childbirth, including Birth Reborn: What Childbirth Should Be (£12.99, Souvenir Press)
‘Today many women need epidurals to deal with the pain of labour, but this doesn’t mean we should automatically be administering them. Instead we should understand more about what will help women deal with the pain of childbirth naturally. 

‘Oxytocin – the most important hormone during childbirth – is a “shy hormone”, which is only properly released if the environment is quiet and unstimulating. When it’s not, which is very common, women need drugs to replace oxytocin’s effect and cope with the pain. It’s therefore time that we rediscovered the importance of privacy and silence during labour.

‘The best situation I know for an easy birth is when there’s nobody around except an experienced, low-profile midwife – not even the father. In this environment, a mum-to-be can allow her primal, unthinking brain to take over and “go to another planet”, which effectively protects her from the pain.

‘Immersion in water is also a way to avoid using drugs. It can reduce the adrenaline a labouring mum releases and make contractions more effective (but only for a period of around two hours). If used at the right time during labour, a birthing pool can compete with an epidural as a form of pain relief. To make birth as easy and pain-free as possible we don’t need to give more women epidurals. We need to get back to basics.’

‘Mums need to feel in control’
Sheila Kitzinger, social anthropologist of birth and author of New Pregnancy & Childbirth: Choices & Challenges (£12.99, Dorling Kindersley)
‘The idea of giving every woman in labour an epidural is ludicrous. While epidurals are very effective, women need to know all the pros and cons in order to come to their own decision, and the cons are numerous.

‘Epidurals add, on average, about an hour to labour, particularly at the pushing stage. This often leads to the use of ventouse or forceps, which in turn increase the risk of an episiotomy or tear. Often a woman’s blood pressure drops too, so oxygen levels to her baby are reduced, slowing the fetal heart rate. Both the mother and baby’s temperatures go up, which results in tests for infection after the birth. There’s also evidence that breastfeeding is more difficult after an epidural delivery, as drugs can pass to the baby meaning he’s not as “clued up” to suckle.

‘But it’s not just the side effects. Some women don’t even need pain relief – they find the birth experience ecstatic and empowering. By giving every woman an epidural before she even feels pain you’d be taking away that opportunity. Many women feel out of control and violated. And all too often this is when they’ve had a “high-tech” labour that’s led to an epidural and all sorts of intervention. Self-hypnosis, acupuncture and visualisation are more effective ways of handling pain, which allow women to feel as if birth is something she’s achieved, rather than something that’s been done to her.’

‘Pregnant women need to know about all the risks’
Sarah Potter, 32, from Plymouth, mum to Georgia, six, and Isaac, 22 months
‘My first labour lasted 17 hours. I tried every type of pain relief, from TENS and gas and air to pethidine, but nothing helped, so when the midwife suggested an epidural, I agreed.

‘But as soon as the epidural wore off, I was in pain. The tops of my legs, my bum and the bottom of my back felt like the skin was burning and it was agony to touch. My doctors said it was probably nerve damage caused by my epidural. It didn’t just hurt; it meant I couldn’t move or look after Georgia properly.

‘The pain has got better but, six years on, I still get it when I’m really cold. I had an epidural on my doctor’s advice and, although I’ll admit it was lovely when the pain stopped, I regret it. I don’t think pregnant women get enough information about the risks of epidurals – you can get long-term numbness and pain like me, headaches, the anaesthetic might only work on half your body and you can even be left paralysed. The risks may be scary, but that’s even more reason to make sure mums know them before they’re in pain, so they’ve got the facts to help them decide.

‘When I was pregnant with Isaac I said there is no way I’m having another epidural. And I didn’t need one – my labour was quicker, just five hours, and I only used gas and air. Which shows that if all women were given epidurals straight away, many would be having drugs they don’t need and putting themselves at unnecessary risk of side effects.’

For more information about the pros and cons of epidurals, and what they entail, visit The Obstetric Anaesthetists' Association (OAA) or search ‘epidural anaesthesia’ at NSH Direct.

Epidurals: the facts

Setting up your epidural
- You will need to have an intravenous cannula and maybe a drip.
- An epidural usually takes 20 minutes to set up and 20 minutes to start to work.
- Some epidurals do not work fully and need to be adjusted or replaced.

Advantages of an epidural
- The dose or type of local anaesthetic can sometimes be altered to allow you to move around the bed. This is a low-dose (or mobile) epidural.
- In general, epidurals do not affect your baby in any way.

Possible problems with your epidural
- Repeated top-ups with stronger local anaesthetic may cause temporary leg weakness and increase the risk of requiring a forceps or ventouse delivery.
- The epidural may slow down the second stage of labour slightly.
- You may develop low blood pressure, itching or a fever during your epidural.
- The epidural site may remain tender but usually only for a few days. Backache is not caused by epidurals but is common after any pregnancy.*