By Beverley A Lawrence Beech
AIMS Journal 1998, Volume 10, No 1
Epidural anaesthesia was developed by a German anaesthetist, Stoeckel, in the early 1990s. By inserting a hollow needle containing a plastic tube into the space between the spinal column and the membranes, which cover the spinal cord, an anaesthetic (usually bupivicane, which is sometimes mixed with fentanyl - an opiate) can be introduced, deadening the nerves and producing powerful pain relief. The injection works within 10 to 20 minutes and, in the majority of cases, provides total pain relief.
However, the most recent study (Green, 1998) of women’s experiences of childbirth revealed that the most commonly mentioned disadvantage of an epidural was loss of sensation. "This disadvantage was volunteered by almost a third of the total sample (31%). Women talked about feeling ‘robbed’ and ‘cheated’ of previous experiences of birth under epidurals and were concerned about feeling they had not ‘participated in’ or ‘contributed anything much to labour’.
The use of epidural anaesthesia was not very widespread until there was an agreement that midwives would be allowed to top it up, after the catheter had been inserted into the woman’s back by the anaesthetist. Bradford (1995) reported that one in five deliveries , rising to one in three in the larger maternity units, the majority of whom were first time mothers, are now managed with epidurals.
In 1987 Sheila Kitzinger published her study of 908 NCT women’s experiences of epidural anaesthesia. It was unfairly criticised for its lack of rigour in selection of participants and for the fact it was a qualitative study rather than the preferred quantitative randomised controlled trials of the medical profession. Her findings reported a 15% failure rate, together with complications including dural tap and dizziness, with 15% of the women complaining of long term back and neurological problems.
The Audit Commission’s survey (Garcia, 1998) revealed that 27% of women reported having epidurals slightly higher than the most recent figure from national data (21% in England and Wales in 1994-5). They also found that availability depended upon the region where the woman lived and that epidural use varied a lot between hospitals, partly because it depends on access to anaesthetists.
The Audit Commission’s Survey also revealed that 69% of women who had caesarean sections had it carried out under epidural and had the advantage of being conscious while the baby was delivered.
An epidural which works effectively will remove all sensation from the waist downwards. It is particularly advantageous for women who have to undergo a caesarean section, as it avoids the adverse effects of recovering from a general anaesthetic. Furthermore, women who have had long, very painful labours, may also find an epidural to be of considerable benefit.
In the early days epidural anaesthesia was promoted as the "Rolls Royce" of anaesthetics and the adverse effects were rarely mentioned. It was not long, however, before AIMS began to receive reports of its more serious adverse effects.
In 1984 Mrs Oladunni Ikumelo, a 29 year-old mother of two, gave birth at Newham Hospital. Her baby, who had breathing difficulties at birth, died two days later, and Mrs Ikumelo remained in a permanent coma. A week before, Mrs Julie Clegg also went into a coma and subsequently died.
Three years before that, Carol Brown was awarded £414,563 after an epidural left her almost totally paralysed. Although very rare, these incidents provoked considerable media interest and as a result Health Rights, for whom I was working at the time, received letters from 70 women who described their experiences a whole range of adverse effects. Backache was the most common complaint; many women had experienced serious headaches, some of which continued at intervals for years; tingling sensations in the limbs and numbness.
In the early 1980s medical journals had little or no information on the adverse effects of epidurals. At a conference in 1986, organised by the Maternity Alliance, Dr Selwyn Crawford, a consultant anaesthetist, was dismissive of the "alleged complications". He was publicly challenged by me to produce some evidence that there was no connection between epidural anaesthesia and the catalogue of long-term effects women were complaining about. In 1990, perhaps as a result of my challenge, his team published the results of a major study into the long term effects of epidural anaesthesia (MacArthur, 1991), and acknowledged that there was a strong association between long term backache and epidurals - the risk was almost doubled (18.9% v 10.5%).
Spinal anaesthesia and a long second stage both increased the risk of backache, but when used for a planned caesarean section there was no increased risk, suggesting that restricted movement and the position of the mother during labour may be a contributory factor, particularly if she had been left in stirrups for some time.
Research (Mercier, 1997) has shown that during the first 2-5 hours after an epidural has been sited there is usually no significant increase in temperature. If, however, labour is prolonged the temperature may increase at a rate of 0.07- 0.15 C per hour. This hyperthermia is usually mild (less than 38 C and is not related to infection. The researchers conclude that fetal tachycardia may occur and the potential for a deleterious effect on the fetus remains controversial. What an understatement!
AIMS members will recall that when it was suggested that a rise in the temperature of a water pool greater than 38 C could cause brain damage in the baby many hospitals unilaterally decided to withdraw their water pool facilities or insist that the women get out of the pool for the birth. An external temperature greater than 38 C will have less affect than a drug which raises the mother’s body temperature to 38 C - yet no-one has suggested withdrawing epidural anaesthesia on the grounds of the risk of brain damage to the baby.
One of the most common complications of epidural anaesthesia is the risk of puncturing the dura. If the anaesthetist overshoots the dural space it causes a puncture out of which spinal fluid can leak; the woman will suffer a severe headache which can last a few days to weeks, and in some cases regularly recur for years. Women who have experienced this kind of headache describe it as a type of "imploding" pain which is quite unlike a normal headache.
The treatment for this problem is to inject a "blood patch" to try and plug the hole and ensure that the mother has total bed rest with the bed tilted. Sitting up can be intensely painful and trying to breastfeed while suffering these complications can be extremely difficult.
Less frequent symptoms were dizziness or fainting and women who had reported numbness in some areas.
"After three days of suffering headaches I had a blood patch performed. since then I have chronic inflammation and muscular spasm in the back and neck with severe pain at times. Five years down the line I am still searching for a diagnosis." D. R. - Antrim, Northern Ireland
In 1992, a research team at the Brigham Women’s Hospital in Boston assessed full term babies over their first month of life, using a Neonatal Behavioural Assessment Scale - 38 from epidural deliveries and 22 from non- medicated deliveries. The babies whose mothers had epidurals showed less alertness and ability to orient over the first month, and their motor behaviour was less mature. This study supports an earlier study by Rosenblatt (1981) which a showed that epidural bupivacaine has significant effects on the baby in the short-term: at six weeks the babies suffered decreased visual skills and alertness, poorer motor organisation and physiological response to stress and control of their own state of consciousness, but even she only checked up to six weeks. What are the long-term effects over the next 20-30 years?
A thorough review (Walker, 1997) in a US journal of the effect of epidurals and narcotics on subsequent breastfeeding found that epidural drugs are present in the labouring mother’s bloodstream, cross the placenta to the fetus and affect the baby’s later behaviour, often causing difficulty with latching on and "inefficient" sucking. These ‘sleepy’ babies may need more time to ‘acquire efficient breastfeeding skills’.
Kitzinger revealed how many women chose an epidural in order to enable them to cope with a medicalised birth which had been taken out of their control. "One of the most striking themes in these birth accounts is women’s sense of disappointment and demoralisation when attached to machines, intravenous drips, catheters, electrodes and other appliances. They went into labour feeling strong and capable but experience a complete take-over of their bodies which renders them helpless and transforms them into passive objects of care."
Epidural anaesthesia is a wonderful technique for a woman who has had a long, difficult and exhausting labour and who feels she cannot cope with the pain any longer; but one must question why our society so terrifies women that they are willing to book a procedure that has the potential of removing them completely from the experience of giving birth before they have experienced the first twinge.
Many of those who choose to book an epidural have never given birth before and, therefore, must be basing their views on what they have seen in the media, or heard from their friends and the professionals who attend them. Ironically, research by Morgan (1980) revealed that 16% of women who booked epidurals at Queen Charlotte’s Hospital felt their birth experience was "unsatisfactory".
The women who had no drugs for pain relief were more satisfied with their labours despite having painful labours.
In the enthusiasm to promote epidural anaesthesia the enthusiasts often overstate their case. Andrew Doughty in the Duncan Flockhart information tape on epidural anaesthesia, which AIMS, incidentally, had withdrawn from the market because of the inaccurate information it contained, and its breach of the ABPI Code of Standards, referred to pain in childbirth as "... the first pain and the constant pain throughout labour." Is it any wonder that women are fearful?
No-one would want to see women in labour in a great deal of pain denied effective pain relief. Unfortunately, in the majority of our centralised consultant units women routinely have their uteri driven by powerful obstetric drugs, at levels which would be impossible in a normal birth; as a result, they are soon shouting for pain relief, and, in the majority of British hospitals, the first method of pain relief available is the drugs’ cabinet.
The enthusiasts of epidurals and other pain killing drugs are often incapable of understanding why women should wish to "give birth naturally", and perceive natural childbirth in hospital terms. They look upon women who want a natural birth as self-centred masochistic perverts, who are only interested in their own ego trip and not interested in the well-being of the baby. The adverse effects on both mother and the baby are generally ignored. "I have discovered that those who chose to go it alone tend to expiate their hours of agony in the delivery suite by climbing up on to a pedestal and making everyone else feel completely lily-livered afterwards. Having a ‘natural’ delivery has become a sort of postnatal brownie point in martyrdom" (Millard, 1997).
It is because of the adverse effects of medically induced and accelerated births on both mother and baby that increasing numbers of women are beginning to demand a return to real midwifery instead of the obstetric nursing seen in so many British hospitals.
References
Advantages:
3 out of 4 women found it gave complete pain relief;
May occasionally be justified in cases of backache labour;
When caesarean operation is justified, it allows the mother to remain awake and alert while her baby is delivered;
Occasionally recommended for women who have pre-eclampsia;
Disadvantages:
Doubles the caesarean operation rates;
70% of primips and 40% of multips will have a forceps delivery;
Three times more likely to increase the length of labour;
One in 20 women found it was of little or no help with pain relief;
Can cause a drop in blood pressure (particularly when the mobile epidural is used);
Can cause a sudden rise in maternal temperature (hyperthermia);
8 in 1,000 women experience severe headaches, some of which can recur for years;
Can cause long term numbness and tingling sensations on the body or limbs;
1 in 4,000 women experience a life-threatening incident;
Can cause permanent paralysis;
Postnatal urinary retention;
Malpresentation of the fetal head;
Threefold increase in the use of oxytocin to speed the labour up;
Slows the labour down;
Can cause shivering and feelings of cold;
Loss of sensation;
Itching (can occur when opiates are used);
Rapidly crosses the placenta;
Can cause sleepiness in the baby;
Affects the baby’s long-term behaviour;
Causes difficulty with breastfeeding.
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