Epidurals in labour - a lifesaver?

Epidurals in labour save lives, why are we still advising against them and denying them to those that benefit the most?

Sarah* wasn’t convinced yet. She had been persuaded to start her labour early after developing a high blood pressure and headache. As she walked her increasingly swollen ankles around the room, the doctors came in on their routine ward round, the consultant obstetrician knelt beside her and talked about the next steps.

“We would really advise you to have an epidural early, probably now to be honest”.

She pointed at me, “the anaesthetic doctor on duty is currently in between cases and getting the epidural in will allow us to control your blood pressure much better. You’ll also be a lot more comfortable when we break your waters and get the oxytocin hormone drip going to strengthen your contractions”.

Sarah had read so many things about epidurals, how they slowed labour down, caused backache and had been told in her antenatal class that if you want a natural birth you shouldn’t have one. Her mother messaged her just now saying she’d never had one in any of her childbirths and should refuse. Yet she’s now being told that it would be good for her and her premature baby.

This story is familiar to every doctor working on labour wards countrywide. There is a lot of misinformation about epidurals and most do not understand how they work and have received conflicting or plainly inaccurate information about them. Here’s how:

The brain, spinal cord and its nerves are bathed in fluid and surrounded by a protective bag called the dura. An epidural is a very thin tube (catheter) that sits just outside this bag and bathes the nerve roots in local anaesthetic and other pain killers. During labour we select a dose of local anaesthetic that blocks the very thin pain nerves but does not penetrate the touch or motor nerves, so in most cases the woman in labour can still feel touch and walk around with no problems. For a caesarean section we increase this dose to block the touch and motor nerves as well.

Epidural insertion is performed by anaesthetists and usually takes around fifteen minutes. They are very safe with serious complications being rare, the commonest being a severe headache in about 1:100 patients. Permanent damage is vanishingly rare and most people gain very good pain relief from their epidural. The epidural can also lower the blood pressure, which may well be a beneficial effect for some patients with a high risk pregnancy.

So epidurals are safe, effective and available to most women in labour. In the last few years there has been a renewed focus on safety in childbirth, culminating in the Ockenden report which highlighted many shortcomings in the NHS service.

I am continually frustrated by our failure to transfer high quality evidence from the world of academia to the frontline and how our patients suffer every day because of it. In April this year, Dr Rachel Kearns and her team in Glasgow reported a study in the British Medical Journal of over half a million women in labour in Scotland, looking at how epidurals affected their likelihood of severe, life-threatening complications such as stroke, heart attack, eclampsia or major haemorrhage. They found that having an epidural reduced the likelihood of these severe complications by 35%, with a much bigger benefit for those that were deemed high risk, or labouring prematurely.

The study also showed that those from less privileged backgrounds and people from ethnic minorities were less likely to have an epidural when their condition indicated they would benefit from it.

Epidurals save mothers’ lives, prevent serious complications and give a more comfortable birth. Yet every day, up and down the country, people are being advised to avoid them in antenatal classes and more overtly by the National Childbirth Trust.

My pregnant colleagues often tell me of their experience in antenatal classes, where epidurals are vilified, their risks exaggerated and “natural” labour and childbirth is revered above all. At this point I look back at my own family history in a poor part of rural Iceland where 120 years ago natural labour was all that existed, and note the sheer number of women and babies that died around birth. Death in childbirth was an everyday occurrence.

Yet epidurals save lives. But why? It may be because reducing pain and lowering blood pressure may have a direct effect on some of the disease processes, such as eclampsia. Labour is also an extremely unpredictable and an emergency threatening the life of the mother or the baby may occur at any moment. Having an epidural in and working probably reduces the time from recognising the emergency to getting the baby delivered safely. Lastly it may simply be that the enhanced midwife care means complications are picked up earlier and dealt with before they become more serious.

So why aren’t we using epidurals more, and why are our underprivileged and ethnic minority patients losing out on the best care?

One of the most satisfying moments in my work is seeing the relief on my patient’s face as her epidural starts working, yet this is often mixed with a sense of guilt and a sense of failure at not having a “natural childbirth”. Here is an intervention that not only relieves pain but can allow you to conserve your energy until you really need it at the end rather than being at the brink of exhaustion, which now seems to protect you from severe harm. The alternatives to an epidural aren’t that natural either, with nitrous oxide (“gas and air”) having some rare but serious complications while being extremely harmful to the environment, whereas most strong pain killers given intravenously can affect the baby and cause breathing difficulties.

Why are we failing our patients from poorer and ethnic minority backgrounds? There is good evidence that patients from these groups are less likely to be offered an epidural, yet it is also known that Asian women are twice as likely and black women are four times more likely to die in pregnancy than their white counterparts. According to the data above, the benefit these groups gain from having an epidural is actually much bigger than the lower risk white group. We should be prioritising these women.

How do we need to change? Epidurals save lives and we should be telling our patients well before they get to the labour ward. We need to start changing the way we talk about epidurals in antenatal classes, on online forums and among groups of friends, giving them accurate information and making recommendations based on facts, not hearsay. We need to change the concept of “natural labour” - no one has failed because they had an epidural, in fact the decision to have one will help them and their babies come through what is naturally a highly dangerous process unscathed, especially if they’re at risk of complications.

We need to safeguard the staffing levels of the labour ward – women are often denied the pain relief they need because of lack of staffing, often having to wait longer or missing out altogether. Midwife staffing is extremely stretched and nationwide there is a 10% vacancy rate for anaesthetists and this stretched service has often been a feature of serious incident reports.

Above all, we need to change culture and embrace epidural pain relief as not just a choice equal to any other, but a medical intervention that saves lives.

*Sarah is fictional but based on many patients I have met and interacted with. Any resemblance to a specific person is solely due to this being an everyday