Epidurals, Emotional Support and Postpartum Depression

An article that appeared in the August, 2014 edition of Anesthesia and Analgesia (one of the most respected professional journals of anesthesia) reports that use of epidural analgesia is associated with a decreased risk of postpartum depression.  The study was performed in Beijing, China at the Peking University First Hospital.  Two hundred fourteen women were included in the study.  One hundred seven had natural childbirth and one hundred seven received epidural analgesia for their labors.  The Edinburgh Postnatal Depression Scale (EPDS) was used to evaluate the women 3 days and 6 weeks following delivery.

Thirty four percent of women who had natural childbirth developed postpartum depression while only 14.0% of women who received epidural analgesia developed depression.  Women who attended prenatal birthing classes and women who breast fed their babies also had lower EPDS scores, i.e. less risk for depression.  Epidural analgesia was associated with lower EPDS scores independent of birthing class attendance and breast feeding.

In a related article, Prevalence and Predictors of Women’s Experience of Psychological Trauma During Childbirth, the authors identify predictors of posttraumatic stress in women following childbirth.  The primary predictors are pain during childbirth, and the delivery of an ill or stillborn child.  Other factors that contribute to posttraumatic stress include hostile and uncaring medical personnel, the feeling of powerlessness, information being withheld from the parturient, interventions without her consent, greater medical intervention, absence of a partner, and lack of emotional support.  A supportive partner and the presence of a female support person are associated with more satisfaction and less stress during delivery.  While 20% to 30% of women experience childbirth as a traumatic event, the authors report that only 2%-6% of women develop posttraumatic stress disorder.

As an anesthesiologist it is nice to have clinical research that gives women additional support for choosing pain control for labor, if she feels she needs it.  I am fortunate to work in an environment where every care giver I know shows a commitment to ensuring that laboring women feel safe, and nurtured throughout their delivery.

The feeling of powerlessness women feel during labor may be caused by many things:  the inability to control and cope with her pain, the inability to participate in decisions about the management of her labor due to poor communication from the medical staff,  and the need for escalating interventions.  Nothing should be done to the laboring woman without her understanding and consent.  Ideally every parturient should have discussed with her physician, or midwife the possible courses her delivery might take before going into labor.  She should be given enough information so that she would understand the need for interventions when they arise, and trust that her care givers were acting knowledgeably in her best interest.  She and her partner should attend prenatal classes to learn and understand what she is about to experience.  Her obstetrician or midwife should take the time to understand her needs and desires for the upcoming delivery.  The care givers should articulate their understanding of their patients’ desires and explain potential decisions for circumstances that arise during labor.  Everyone should be on the same page, on the same team.  Choose your metaphor.

The most important relationship, though, should be between the woman giving birth and her partner.  And the partner’s purpose should be to support her emotional and physical needs at all times.

The pain of childbirth is very likely to be the most painful event of a woman’s life.  Until labor begins, it is impossible to anticipate how she will cope with it.  Before the day arrives a couple may have agreed on a birth plan of natural childbirth.  Good for them.  But when labor starts some women find that the intensity of the pain is something she cannot endure.  There is a difference between pain and suffering.  If she chooses to change her mind and ask for pain relief, be it intravenous medication or an epidural, she needs her partner’s support.

I have administered epidurals to women who remain in tears after the epidural has removed their pain.  When I have asked these women why they are still crying I’ve been told, “My husband is mad at me for getting an epidural.”  I’ve also watched an entire family badger a young woman trying to have natural childbirth to make her either have an epidural or have a cesarean section just to get it over with because, “We traveled a long way to be here for this.”  Women who feel guilt for letting down their partners or family are more likely to suffer postpartum depression or exhibit posttraumatic stress.

My message to pregnant women, their partners and family is this:

  1. Get as informed about your pregnancy and the process of birth as you can.  Learn what to expect.
  2. Choose a qualified obstetrician or midwife, one who is willing to listen and plan with you.
  3. I strongly suggest finding a doula, the female support person who will be there with every contraction.
  4. Agree on a birth plan, and agree to be flexible.  You won’t know what labor is like until you’re in it.  Don’t make any irrevocable agreements with anyone.
  5. The woman having the baby is in charge.  This is most importantly her day.  All others are there to support her needs, and decisions.
  6. If he, she, they cannot be supportive they are not welcome and should be kept away.
  7. The birth of your healthy child should be a joyous, exciting, happy event.  If the birth doesn’t follow your plan, don’t let it spoil a wonderful conclusion.

The Epidoula

P.S.  If you labor naturally for hours then decide to get an epidural you still get credit for all the natural childbirth you endured!  My rule.

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Ding T, et. al.  Epidural Labor Analgesia Is Associated with a Decreased Risk of Postpartum Depression: A Prospective Cohort Study. Anesth Analg 2014;119:383-92.

Soet JE, Brack, GA, and Dilorio C. Prevalence and Predictors of Women’s Experience of Psychological Trauma During Childbirth. BIRTH 30:March 2003.

How Does an Epidural Affect the Duration of Labor?

Let’s address the duration of labor comparing women who choose to give birth naturally to women who have an epidural.

First, not all women are alike, not all labors are alike, and not all anesthetics are alike.  For this reason, there is tremendous variability in the duration of labor no matter how you have your baby.

That being said, the scientific literature reviewed by Drs. Anim-Somuah, Smyth, and Jones for the Cochrane Collaboration in their document Epidural versus non-epidural or no analgesia in labour concludes that epidural anesthesia will prolong your labor by about 14 minutes.  The reviewers looked at eleven articles that examined the first stage of labor and thirteen articles that considered the second stage of labor.  The first stage of labor is the time it takes to achieve complete dilation and effacement, and the second stage is the time it takes to deliver the baby once you are completely dilated.  Concerning the first stage of labor, the authors concluded that , “There was no evidence of a significant difference in this outcome.”  And about the time it takes after reaching complete dilatation to deliver the baby they state, “Women with epidural analgesia had a statistically significant longer second stage of labour.”  Women with epidurals labor about 14 minutes longer, on average, than women having natural childbirth.

Why should this be true?  We can’t be sure why women who ask for epidurals labor longer.  It may be that more painful labor is itself associated with longer labor.

The process of receiving an epidural may prolong labor.  One of the side effects of an epidural is a tendency for the woman’s blood pressure to drop.  In order to prevent the drop in blood pressure anesthesiologists and anesthetists administer extra intravenous fluid just prior to placing the epidural.  This intravenous fluid may dilute the naturally secreted oxytocin that is the driver of the uterine contractions.  When one observes the graph of the uterine contractions they tend to occur less frequently immediately after the fluid administration, and return to their normal pattern after about 20 minutes.  It takes about 20 minutes for the kidneys to clear that additional fluid from your blood stream.

Epidural anesthesia not only relieves your pain, but it affects the ability of your skeletal muscles to function normally below the level of the anesthetic.  We do not allow women to walk after epidurals at our hospital even with very “light” epidurals because the ability to walk is impaired and the woman may fall.  The abdominal muscles may become weaker also if the anesthetic is high enough to affect these muscle.  If the abdominal muscles are weak it may be harder to push out the baby.  As the time for delivery approaches the anesthetic may be reevaluated and decreased if need be to allow for better pushing.  Usually this is not a problem.

Some people believe that a woman’s pelvic floor muscles must be functioning well to help guide the baby’s head out of the pelvis and into the birth canal.  With an epidural these muscles also are affected so that this help is not available.

What do we see clinically?  (These comments reflect what we commonly see in the delivery room, so do not represent scientific study.)  When women have epidurals they naturally (not in the natural childbirth sense) relax.  Some women who are experiencing unmedicated labor cannot relax their pelvic floor muscles.  These muscles must relax so that the baby can pass through them.  So until they are able to relax the results of the work of their labor may not be evident…they won’t dilate.  When the woman in natural childbirth finally “surrenders to the pain” she is able to relax the pelvic floor and allow the baby to descend, her cervix to dilate, and deliver.  Very often women who have tried to deliver naturally and opt for an epidural deliver rapidly after the epidural.  I believe this happens because she has been doing the hard work of labor, but her unrelaxed pelvic floor muscles won’t allow her to progress.  The epidural does the same thing as the women who can break through the pain herself.

References:

Anim-Somuah M, Shyth RMD, Jones L.  Epidural versus non-epidural or no analgesia in labour.  Cochrane Database of Systematic Reviews 2011, Issue12.

Bofil JA, Vincent RD, Ross EL, Martin RW, Normal PF, Werhan CF, et al.  Nulliparous active labor, epidural analgesia and cesarean delivery for dystocia.  American Journal of Obstetrics and Gynecology 1997;177:1465-70.

Chen LK, Hsu HW, Lin CJ, Huang CH, Tsai SK, Lee CN, et al. Effects of epidural fentanyl on labor pain during the early period of the first stage of induced labor in nulliparous women. Journal of the Formosan Medical Association 2000;99(7):549-53.

Clark A, Carr D, Loyd G, Cook V, Spinnato J. The influence of epidural analgesia on cesarean delivery rates: a randomised, prospective clinical trial. American Journal of Obstetrics and Gynecology 1998;179:1527-33.

Gambling DR, Sharma SK, Ramin SM, Lucas MJ, Leveno KJ, Wiley J, et al. A randomized study of combined spinal-epidural analgesia versus intravenous meperidine during labor: impact on cesarean delivery rate. Anesthesiology 1998;89:1336-44.

Howell C, Kidd C, Roberts W, Johanson R, Upton P, Lucking L, Jones P, et al. A randomised control trial of epidural compared with non-epidural analgesia in labour. BJOG: an international journal of obstetrics and gynaecology 2001;108(1):27-33.

Jain S Arya S, Gopalan S, Jain V. Analgesic efficacy of intramuscular opioids versus epidural analgesia in labor. International Journal of Gynecology & Obstetrics 2003;83:19-27.

Long J, Yue Y. Patient controlled intravenous analgesia with tramadol for pain relief. Chinese Medical Journal 2003;116(11):1752-5.

Lucas M, Sharma S, McIntire D, Wiley J, Sidawi J, Ramin S, et al. A randomized trial of labor analgesia in women with pregnancy-induced hypertension. American Journal of Obstetrics and Gynecology 2001;185:970-5.

Morgan-Ortiz F, Quintero-Ledezma J, Perez-Sotelo JA, Trapero-Morales M. Evolution and quality care of labour and delivery in primiparous patients who underwent early obstetric analgesia. Gynecologia y Obstetricia de Mexico 1999;67:522-6.

Nafisi S.  Effects of epidural lidocaine analgesia on labor and delivery: a randomized, prospective, controlled trial. BMC Anesthesiology 2006;6:15.

Sharma SK, Alexander JM, Messick G, Bloom SL, McIntire DD, Wiley J, et al. Cesarean delivery: a randomized trial of epidural versus intravenous meperidine analgesia during labor in nulliparous women. Anesthesiology 2002;96(3);546-51.

Thalme B, Belfrage P, Raabe N. Lumbar epidural analgesia in labaour: I. Acid-base balance and clinical condition of mother, fetus and newborn child. Acta Obstetricia et Gynecologica Scandinavica 1974;53:27-35.

Thorp JA, Hu DH, Albin RM, McNitt J, Meyer BA, Cohen GR, et al. The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial. American Journal of Obstetrics and Gynecology 1993;169:851-8.

 

My Manifesto

I believe that every woman has the right to have the kind of experience at the birth of her child that she would like to have.
I believe the safest, and therefore the best place, to have her baby is in a properly staffed hospital dedicated and committed to support her and her wishes.  Approximately 4 percent of births are complicated by events that threaten the health and life of either the mother or the baby or both.  A hospital with a full-time dedicated labor and delivery unit is the safest place to be when life-threatening events occur.  Although I don’t think it is as safe as a hospital, I support a woman’s choice to delivery at home or a birthing center as long as she is aware of the relative risks.
I believe in natural childbirth and medicated childbirth.
I believe in doulas, midwives, labor nurses and physicians.  Henceforth, the term “doula” shall be inclusive of any attendant whose job it is to support the laboring woman, unless otherwise noted.
I do not believe in “husband coached” childbirth in most cases. I believe most husbands (or fathers of the baby, etc.) are emotionally ill-equipped to be good birth coaches.
I believe doulas are the best coaches for childbirth for the mother and the father. While giving comfort to the laboring woman the doula frees the father to support his partner and experience the birth of his child in the best way he can, as well.  (Having a doula attending your birth doesn’t preclude the baby’s father giving physical and emotional support.  Its just nice to have a professional who has been in that situation before.)

I believe in walking, birthing balls, and the freedom of the woman to assume the best birthing position for her.

I don’t believe in water births.  If the birth could take place in a free flowing stream or natural spa, or on the beach with water ebbing and flowing where urine and feces that contaminate the water are continuously washed away, I could go for that.  But having a baby in a tub where the water cannot be refreshed is no different, to me, than birthing in a toilet.  But I support a woman’s right to choose.

So this is my manifesto.  A woman has a right to choose what is best for herself.  Her family and peers should support her right to choose, and not vilify her if she should choose differently than they would.