Study shows confidence in epidurals

I‘ve been around long enough to remember the “bad old days” in obstetrics. Pain relief, if it existed at all, was kind of an all or nothing phenomenon. Women in my mother’s generation were knocked out completely, and introduced to the baby they bore well after the fact. When I started my residency, women might have gotten IV Demerol, but only in early labor. If it was given too close to delivery, the baby could come out too sleepy to remember to breathe. If a woman was “lucky” she might get a spinal right before delivery, but then lose all urge to push that little critter out. A lot of us got good at forceps deliveries because of those spinals.

Then epidurals came along. At first there was concern that there could be some bad effects on the baby. But many studies have been done since the early days, and babies do just fine with epidurals. Moms do fine too: both mom and baby don’t suffer the sedating effects of IV narcotics. And another annoying side effect of narcotics is also less common when women use epidurals for pain relief rather than IV narcotics: They don’t toss their cookies anywhere near as often.

Then we worried that epidurals led to more frequent C-sections. Multiple studies have since shown us that epidural use, separated from other factors, makes it no more likely that a C-section will be necessary.

Finally, we worried that if a woman got her epidural “too early,” before she was dilated to four or five centimeters, a C-section would be more likely. In fact, the American College of Obstetrics and Gynecology has recommended that, in first pregnancies, epidural be delayed until the laboring woman reaches that point. Researchers at Northwestern University set out to see if, indeed, early epidurals lead to more C-sections, and they reported their findings in the New England Journal of Medicine.

They studied 750 women who were in labor with their first baby and who were not yet dilated to 4 centimeters. After agreeing to participate in the study, the women were assigned to one of two groups. The first group got an IV narcotic (we call them opioids) at their first request for pain relief. At their second request, if they were still not dilated to 4 centimeters, they got a second dose of IV medicine.

If they were dilated beyond 4, or if this was the third request for pain medicine, they got an epidural.

The second group got a dose of an opioid in their spinal fluid (called the intrathecal space.) At their second request for pain medication, an epidural was placed, no matter how far along they were.

In both groups, once the epidural was in place, the laboring woman could push a button whenever she needed more pain medicine.

Their findings were most reassuring. Women who had earlier epidurals (combined with the spinal dose) had lower pain scores both at their second request for pain medicine and in between doses. They had much less nausea and vomiting.

But most important, there was no statistical difference in C-section rate in the two groups.

Another finding that interested the researchers is that the first stage of labor – labor up to complete dilatation – was actually 90 minutes shorter in the in the early spinal/epidural group.

Previous studies have suggested that the first stage of labor is longer in women who choose epidurals.

Perhaps the early opioid spinal dose, which is different from the classic epidural, both in site of action and medication used, can actually have a beneficial effect on the course of labor.

Of course, there are many women who choose a labor without medications. But the majority of women experiencing their first labor elect to have an epidural.

This study should reassure them, and their physicians, that they can have pain relief early in labor and not risk an increased chance of having a Caesarean section.